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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/emergenciesetiolOOhowe 


EMERaE^OIES. 


THE    ETIOLOGY,    PATHOLOGY,    AND    TREATMENT   OF    THE    ACCI- 
DENTS,  DISEASES,   AND   CASES   OF  POISONING 
WHICH   DEMAND   PROMPT   ACTION. 


DESIGNED    FOR 


STUDENTS  AND  PRACTITIONERS  OF  MEDICINE. 


BY 

JOSEPH  W.   HOWE,  M.  D., 

AITTHOE   OF   "  THE     BEEATH,  AND  THE  DISEASES    WHICH    GIVE    IT    A    FETID    ODOR ; "    "  WINTEB 
HOMES  FOE    INVALIDS,"   ETC.;    LATE    PEOFESSOK   OF    CLINICAL   SUEGEET  IS    BELLETTTE 
HOSPITAL   MEDICAL   COLLEGE;    FELLOW   OF  THE    NEW   TOEK   ACADEMY  OF  MEDI- 
CINE;    MEMBER     OF     THE     NEW     TOEK     SITEGICAL,     PATHOLOGICAL,     AND 
COtTNTT  MEDICAL   SOCIETIES;    CONSULTING   PHYSICIAN  TO   HOSPITAL 
FOB  DISEASES   OF  THE   NOSE,   MOUTH,  AND   THEOAT  ;    VISITING 
STJEGEON   TO   CHAEITT   AND    ST.   FEANCIS    HOSPITALS. 


FOURTH  EDITION. 


FEW    YORK: 

D.   APPLETON   AND    COMPANY, 

1,  3,  AKD    5   BOND    STREET. 

1886. 


CoPTBionr,  IS'l,  1684. 
By  D.  APPLETON  AND  COMPANY. 


PREFACE  TO  THE  FIRST  EDITION. 


This  volume,  as  its  title  indicates,  is  designed  as  a  guide 
in  the  treatment  of  cases  of  emergency  occurring  in  medi- 
cal, surgical,  or  obstetrical  practice.  I  have  endeavored  to 
combine,  in  a  narrow  compass,  all  the  important  subjects, 
giving  special  prominence  to  points  of  practical  import  in 
preference  to  theoretical  considerations,  and,  with  the  re- 
sults of  my  own  personal  observation,  uniting  the  latest 
views  of  European  and  American  authorities. 

J.  W.  H. 

86  West  24th  Street,  June  1,  ISVl. 


OOl^TENTS. 


CHAPTER  I. 
HJEMOBBHA  GE. 

General  Considerations. — Eesults  of  Negligence.  —  Arterial  and  Venous 
Haemorrhage. — Effects  of  Profuse  Haemorrhage. — Natural  and  Arti- 
ficial Methods  of  suppressing  Haemorrhage. — Haemorrhagic  Diathesis. — 
Constitutional  Treatment. — Transfusion,      .  .  .  .  .9 

CHAPTEE  II. 
SPECIAL  ffyEJfOJmffAGES. 

Bleeding  from  the  Nose,  Mouth,  Lungs,  Stomach,  Intestines,  Kidneys,  Ure- 
ters, Bladder,  Urethra,  Erectile  Tissue  of  Peuis. — Ecchymosis,   .  .    21 

CHAPTER  in. 
E^MOBRRAGE  FROM  THE  UTERUS. 

Menorrhagia. — Metrorrhagia. — Accidental  Haemorrhage. — Placenta  Praevia. 
— Post-partum  Haemorrhage,   .  .  .  .  .  .  .41 

CHAPTEE  IV. 
WOUNDS  OF  IMPORTANT  OBGANS. 

Wounds  of  the  Throat,  Lungs,  Pericardium,  Heart,  Abdomen,  Intestines, 
Bladder,  Perinaeum,  Joints. — Rupture  of  Liver,  Perineal  Section,  Para- 
centesis, Thoracis. — Gunshot-Wounds,         .  .  .  .  ,47 

CHAPTEE  V. 
WOUNDS  OF  ARTERIES  AND    VEINS 

Ligation  of  large  Arteries ;  Arteria  Innominata,  Subclavian,  Common  Carotid, 
Axillary,  Brachial,  Eadial,  Ulnar,  Palmar  Arch,  Femoral,  Popliteal,  An- 
terior Tibial,  Posterior  Tibial. — Air  in  the  Veins. — Causes  of  Death. — 
Treatment,         .  .  .  .  .  .  .  .  .65 


6  CONTENTS. 

CHAPTER  VI. 
poisoxED  yrouxDS. 

TAQ* 

Dissecting  "Wounds. — Hydrophobia  in  Dogs. — IlydroplioLia  in  Man, — Eattle- 
snake-Bites.— Insect-Bites. — Ceatipede.— Tarantula.— Scorpion,  .  .    14 

CHAPTER  VII. 

EXTRACTION  OF  FOREIGN  BODIES. 

Foreign  Bodies  in  the  Larynx,  Trachea,  Bronchial  Tubes,  Pharynx,  (Esoph- 
agus, Eyes,  Nose,  Ears,  Urethra,  Bladder,  and  Rectum, — Tracheotomy. — 
Laryngotouiy. — (Esophagotomy,        .  .  .  .  .  .85 

CHAPTER  VIII. 

BURNS  AND  SCALDS— EFFECTS  OF  COLD. 

Varieties  of  Deformities  produced  by  Bums. — Operation  for  closing  the  Eye. 
— Spontaneous  Combustion  —  Classification  of  Burns  —  Constitutional 
Symptoms. — Duodenal  Ulcer — Causes  of  Death  —  Post-mortem  Ap- 
pearance.—Effects  of  Cold.— Frost-Bite,       .  .  .  .  .101 

CHAPTER  IX. 

STRANGULATED  HERNIA. 

Causes  and  Symptoms  of  Strangulation. — Ileus. — Volvulus. — Operations  for 
Inguinal  and  Femoral  Hcmiae. — Taxis,  .....  112 

CHAPTER  X. 
LOSS  OF  CONSCIOUSNESS. 

COMA. 

Coma  from  Cerebral  Extravasation,  Depressed  Fracture,  Pressure  of  Inflam- 
matory Products,  Embolism,  Thrombosis,  Uraemia,  Alcohol,  Hysteria, 
Epilepsy. — Concussion,  .  .  .  .  .  .  .118 


CHAPTER  XI. 
LOSS  OF  CONSCIOUSNESS-iCo^nsvm). 


Syncope  from  Loss  of  Blood — Thrombi  of  the  Pulmonary  Vein — Anaemia.— 
Mental  Emotions — Blows  on  the  Ep-gastrium — Collapse,  .  .138 


CONTENTS.  7 

CHAPTEK  XII. 
ASPnrxiA. 

rAOE 

Respiratory  Apparatus. — Effects  of  Non-a5ration  of  Blood. — Strangulation. — 
Compression  of  the  Thorax. — Inhalation  of  Poisonous  Gases. — Signs  of 
Death. — Drowning. — Injuries  to  the  Spinal  Cord. — Strychnia,      .  .  139 

CHAPTER  XIII. 

SUmiMOKE. 

Synonymes. — ^FLrst  Eecorded  Cases. — Sunstroke  in  Crowded,  Overheated 
Buildings. — Varieties  of  Sunstroke. —  Symptoms. —  Treatment. —  Post- 
mortem Appearances,  ........  158 

CHAPTEE  XIV. 
I>YSP]sf(EA. 

Causes  of  Hurried  Eespiration. — Dyspnoea  in  Asthma,  True  and  False  Croup, 
Congestion  of  the  Lungs,  Cardiac  Disease,  Pulmonary  CEdema,  Pulmo- 
nary Apoplexy,  .  .  .  .  .  .  .  .165 

CHAPTEE  XV. 
(EDEMA    GLOTTIDIS. 

Location  of  the  Effusion. — CEdema  Glottidis  in  Bright's  Disease — Inflamma- 
mation — Collateral  QSdema — Symptoms. — Treatment,        .  .  .  172 

CHAPTEE  XVL 
CON  YUL  S  I  0  ITS. 

Tonic  and  Clonic  Spasms. — Irritation  of  the  Tuher  Annulare. — Infantile 
Convulsions. — Convulsions  from  Urajmic  Poisoning,  Cerebral  Extrava- 
sation, Hysteria,  Alcohol,  Epilepsy,  Tetanus,         ....  176 

CHAPTEE  XVII. 
SUSPEifDED  F(ETAL  ANIMATION. 

Pressure  on  the  Umbilical  Cord. — Injury  to  the  Brain. — ^Eupture  of  Funis.— 
Asphyxia. — Syncope. — Congestion  of  Brain,  ....  195 

CHAPTEE  XVIII. 
COMPLICATIONS  OF  LABOR,  ETC. 

Eupture  of  the  Uterus. — Prolapse  of  the  Funis. — Short  Cord. — Irregular  Pre- 
sentations and  Positions. — Tamponing  the  Vagina,  .  .  .  198 


CONTENTS. 


CHAPTER  XIX. 


Retention  of  Urine. — Dislocation  of  tho  Neck. — Injuries  from  Lightning. — 
Colic, 207 


CHAPTER  XX. 
TOXICOLOGY 

NAECOTIO  P0I80NB, 

Opium,  Belladonnti,  Ilyoscyamus,  Aconite,  Tobacco,  Stramonium,  Chloro- 
form, Ether,  Alcohol,  Chloral,  Prussio  Acid,  Hemlock,  Lobelia,  Calabar 
Bean,  Woorara,  Mushrooms,  Upas  Tree,      .  .  .  ,  .211 


CHAPTER  XXI. 
IRRITANT    POISONS. 

CanthariJes,  Croton-oil,  Colchicum,  Veratria,  Black  and  White  Hellebore, 
Drastic  Cathartics,       .  .  .  .  .  .  .  .235 

CHAPTER  XXII. 
METALLIC  POISONS. 

Arsenic,  Corrosive  Sublimate,  Copper,  Lead,  Tartarized  Antimony,  Zinc, 
Kitrate  of  Silver,  Phosphorus,  .  .  .  -  .  .329 

CHAPTER  XXIII. 

CORROSIVE    ACIDS. 

vjxalic  Acid,  Sulphuric  Acid,  Muriatic  Acid,  Nitric  Acid,  Carbolic  Acid,         254 

CHAPTER  XXIV. 
CORROSIVE  ALKALIES. 

Carbonate  of  Potash,  Caustic  Potash,  Nitrate  of  Potash,  Binoxalate  of  Pot- 
ii£b,  Ammonia,  .  .  .  .  .  .  .  .258 


EMERGENCIES, 


HOW    TO    TEEAT    THEM, 


CHAPTER   I 


HEMORRHAGE. 


General  Considerations. — Eesults  of  Negligence. — Arterial  and  Venous  Haemor- 
rhage.— Effects  of  Profuse  Hsemorrhage. — Natural  and  Artificial  Methods  of 
suppressing  Hsemorrhage. — Hsemorrhagic  Diathesis. — Transfusion. 

Medicine  is  often  reproaclifully  characterized  as  a  sci- 
ence of  experiments,  a  profession  remarkable  for  its  brill- 
iant uncertainties  and  conflicting  theories.  Superficial  ob- 
servation and  imperfect  means  of  study  gave  origin  to  this 
sentiment  when  the  healing  art  was  in  its  infancy,  and  it 
is  yet  retained  by  a  few  who  find  it  a  convenient  excuse 
for  all  their  errors.  There  are  conflicting  theories  in  medi- 
cine as  well  as  in  other  professions.  Such  theories  are  the 
mainsprings  of  progress ;  they  develop  strength  and  incite 
to  laborious  investigations. 

Uncertainty  appertains  to  every  science  that  has  not 
arrived  at  its  maximum  development :  but  it  is  not  espe- 
cially characteristic  of  our  profession.  The  discoveries  of 
to-day  will  necessarily  be  modified  by  the  developments  of 


10      EMERGENCIES,  AND  ^0^y  TO  TREAT  TUEM. 

to-morrow,  and  the  theories  of  our  own  time  will  be  replaced 
by  tlie  truths  of  the  future. 

The  cases  of  emergency,  considered  in  the  following 
pages,  are  entirely  exempt  from  the  charge  of  uncertainty ; 
but  they  are  followed  by  disastrous  results  when  treated  by 
incompetent  persons.  The  internes  of  our  large  hospitals 
know  that  it  is  not  an  uncommon  occurrence  for  patients  to 
be  admitted  in  art Icido  mortis  j  their  chances  of  recovery 
destroyed  by  the  neglect  or  ignorance  of  the  attendant  out- 
side. The  following  cases  from  my  hospital  note-book  may 
be  of  interest  as  examples  : 

Case  I. — Martin  C,  aged  twenty;  occupation,  machinist ; 
was  admitted  to  ward  eleven,  Bellevue  Hospital,  suffering 
from  incised  wounds  of  the  wrist  and  palm  of  the  hand.  On 
arriving  at  the  hospital,  he  was  partiallj^  insensible  from  loss 
of  blood.  The  voice  could  not  be  raised  above  a  whisper, 
and  the  face  was  extremely  pallid  and  anxious.  The  pulse 
could  with  difficulty  be  distinguished.  The  entire  clothing 
of  one  side  of  the  body  was  saturated  with  blood.  On 
making  an  examination,  I  found  that  a  folded  handkerchief 
was  bandaged  crver  the  centre  of  the  wrist,  and  that  the 
wound  in  the  palm  was  untouched.  The  pad  was  placed  on 
the  wrist  as  if  the  greatest  care  had  been  exercised  to  avoid 
pressing  on  the  radial  or  ulnar  arteries.  The  sides  of  the 
pad  scarcely  reached  them.  This  dressing  was  applied  by  a 
so-called  surgeon  shortly  after  the  wounds  were  inflicted. 
The  haemorrhage  in  this  case  was  easily  controlled  by  liga- 
tures. The  patient,  however,  developed  phlegmonous  ery« 
sipelas,  and,  not  having  sufficient  vitality  to  carry  him 
through,  succumbed  on  the  fifth  day  after  his  admission. 

Case  II. — John  M.,  aged  thirty ;  occupation, laborer;  fell 


HEMORRHAGE.  ]  1 

from  the  front  platform  of  a  car  at  Harlem  and  bad  his  riglit 
foot  crushed  by  the  wheel.  His  friends  carried  him  to  a 
Burgeon  in  the  neighborhood,  who  placed  an  ordinary  band- 
age on  the  limb,  without  any  compress  over  tlie  vessels.  In 
bringing  the  man  to  the  hospital,  the  rough  jolting  of  the 
carriage  set  the  wound  bleeding,  and  by  the  time  he  reached 
his  destination  he  was  apparently  lifeless.  The  vessels  were 
tied,  and  stimulants  administered,  but  he  never  rallied. 
Death  occurred  six  hours  after  his  admission.  His  injuries, 
independent  of  the  haemorrhage,  might,  indeed,  have  termi- 
nated his  life ;  still  the  chances  would  have  been  in  his  favor 
if  a  compress  had  been  applied  to  the  limb  to  prevent  bleed- 
ing. The  fact  that  such  a  thing  was  not  done  showed  either 
culpable  negligence  or  deplorable  ignorance.  It  is  through 
such  treatment  that  the  percentage  of  deaths  from  accidents 
is  increased  to  an  unnecessary  degree.  To  remedy  these 
evils,  a  thorough  knowledge  of  the  treatment  of  accidents 
should  be  impressed  on  the  memory  as  indelibly  as  are  the 
letters  of  the  alphabet.  I^or  should  this  knowledge  be 
entirely  confined  to  medical  colleges  and  professional  men. 
Non-professionals,  with  a  moderate  share  of  common-sense, 
might  learn  to  control  haemorrhage,  relieve  syncope,  extract 
foreign  bodies,  resuscitate  the  drowned,  and  administer  an 
antidote  in  cases  of  poisoning.  Such  knowledge  would  as- 
sist, rather  than  retard,  the  labor  and  usefulness  of  profes- 
sional persons. 

The  varieties  of  haemorrhage  constitute  a  large  and  im- 
portant class  of  emergencies.  Loss  of  blood,  when  profuse, 
is  always  attended  with  danger,  and  necessitates  immediate 
treatment. 

The  term  "  haemori'hage  "  is  applied  to  a  flow  of  blood 


12  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

from  any  part  of  the  vascular  system,  with  or  Avithoul  rup- 
ture of  the  vessels. 

Arterial  hoemorrhage  is  attended  with  serious  conse- 
quences. It  is  readily  recognized.  The  blood  is  of  a  bright- 
scarlet  color,  and  is  forced  out  in  successive  jets ;  each  jet  is 
synchronous  with  the  movements  of  the  heart.  This  char- 
acteristic spurting  is  caused  by  the  intermittent  force-pump 
action  of  the  heart  driving  out  the  blood.  Yenous  ha3mor- 
rhage  is  distinguished  from  arterial  by  the  dark-blue  color  of 
the  blood,  which  never  flows  in  repeated  jets,  but  oozes 
slowly  from  the  wounded  surface.  Yenous  blood  is  travel- 
ling foward  the  heart,  and  there  is  consequently  no  force  be- 
hind to  cause  a  more  rapid  flow.  This  form  of  htemorrhage 
is  comparatively  harmless,  unless  occurring  from  very  large 
veins. 

In  large  wounds,  arterial  twigs  are  divided,  and  arterial 
bleeding  predominates.  In  small  wounds  there  is  mixture 
of  both  varieties.  The  blood  is  dark  red,  and  comes  away 
gradually. 

The  constitutional  symptoms  accompanying  external  or 
internal  haemorrhage  are  distinctly  marked.  The  lips  and 
cheeks  rapidly  assume  a  pallid  hue.  Tliere  are  great  restless- 
ness and  anxiety.  The  extremities  are  cold,  and  often  bathed 
in  clammy  perspiration ;  respiration  is  weak  and  sighing ; 
the  pulse  becomes  small  and  rapid ;  its  increased  rapidity 
being  due  to  the  efforts  of  the  heart  to  make  up,  by  frequent 
impulses,  the  diminished  quantity  of  blood  sent  to  the  tis- 
sues. The  patient  complains  of  vertigo  and  dimness  of 
vision,  is  unable  to  articulate  plainly,  and  finally  lapses  into 
a  state  of  unconsciousness.  The  heart  has  partially  suspend- 
ed its  movements,  and  the  pulse  is  imperceptible.    With  the 


nJEMORRHAGE.  13 

gjncope  the  bleeding  ceases.  There  is  not  sufficient  vitality 
remaining  to  force  more  blood  from  tlie  injured  vessels,  nor 
action  in  the  heart  to  keep  up  the  circulation.  Here  Nature 
takes  the  place  of  surgical  skill.  The  stoppage  of  the  cur- 
rent allows  the  blood  time  to  coagulate  in  the  mouths  of  the 
bleeding  vessels,  and  to  plug  them  up  completely  before  con- 
sciousness is  restored  or  the  heart  again  at  work.  But, 
should  this  fail  to  occur,  the  signs  previously  enumerated  are 
intensified,  A  slight  convulsive  movement  ensues,  and  the 
patient  dies.  Occasionally,  death  occurs  during  a  sudden 
effort  of  the  patient  to  sit  up  in  bed,  or  in  some  other  active 
movement.  The  effort  creates  a  necessity  for  increased  ac- 
tion of  the  heart,  which  is  unable  to  respond  to  the  call,  and 
paralysis  of  the  organ  results.  The  same  thing  takes  place 
sometimes  when  persons  are  greatly  debilitated  by  disease ; 
in  rising  to  dress,  or  crossing  the  room  quickly,  they  drop 
dead.  The  pulsations  are  abnormally  multiplied,  as  in  the 
former  case. 

There  is  a  peculiar  condition  of  the  system  known  as  the 
hsemorrhagic  diathesis,  in  which  the  slightest  scratch  or 
wound  of  any  description  produces  persistent  bleeding.  The 
disease  is  hereditary,  and  both  sexes  are  equally  liable  to  it. 
In  Germany,  beyond  other  countries,  the  largest  number  of 
cases  have  appeared.  Seemingly  insignificant  wounds  in 
persons  of  this  diathesis  endanger  life.  Lacerated  wounds 
of  the  gums  from  extraction  of  teeth  or  abrasions  in  mucous 
canals,  which  cannot  be  reached  by  local  applications,  are 
the  most  serious.  The  blood  does  not  exhibit  the  usual  ten- 
dency to  coagulate.  The  cut  vessels  are  lax  and  patulous, 
their  contractile  power  is  diminished,  and  the  principal 
natural  means  of  suppressing  haemorrhage  are  unavailable. 


14      EMERGENCIES,  AND  BOW  TO  TREAT  THEM. 

Our  knowledge  of  its  patliology  is  limited,  and  chemical 
analysis  shows  that  the  blood  possesses  the  same  elements, 
in  normal  proportions,  as  it  does  in  persons  entirely  free 
from  this  disease.  The  vascular  canals  in  one  or  two  in- 
stances have  been  found  thinned,  but  in  the  majority  of  cases 
there  is  no  marked  alteration. 

The  general  treatment  of  haemorrhage,  when  thoroughly 
understood,  can  be  applied  in  special  cases  without  difficulty. 
In  this  connection  it  will  be  well  to  consider  Nature's  meth- 
ods of  closing  bleeding  vessels,  before  we  pass  to  the  ap- 
pliances of  art.    Our  efforts  copy  !Rature  as  far  as  possible: 

1.  There  is  contraction  of  the  muscular  fibres  in  the 
artery,  induced  by  the  injury  and  by  admission  of  air.  The 
contraction  closes  the  wounded  orifice. 

2.  The  artery  retracts  within  its  sheath,  the  effused 
blood  coagulates  in  front  of  it,  and  th>e  haemorrhage  conse- 
quently ceases. 

3.  The  blood  may  collect  on  the  surface,  coagulate,  and 
compress  the  wounded  vessel. 

4.  If  the  cut  vessels  are  small,  the  bleeding  will  cease  by 
coagulation  of  blood  within  them. 

5.  Syncope,  by  allowing  coagulation  to  take  place  before 
the  circulation  is  renewed,  prevents  a  recurrence  of  the 
bleeding. 

In  all  our  surgical  methods  of  stopping  external  haemor- 
rhage, there  are  none  more  efficient  or  available  ihojijpressuTe. 
It  can  be  employed  over  the  main  artery  of  the  limb,  be- 
tween the  wound  and  the  heart,  or  directly  upon  the  wound- 
ed part.  "When  the  main  artery  is  to  be  compressed,  an  in- 
strument called  the  tourniquet  is  generally  used.  If  this  is 
not  at  hand,  a  field  tourniquet  may  be  applied  in  the  fol- 


HEMORRHAGE.  15 

lowing  manner:  A  liandkercliief  is  passed  loosely  around 
the  limb  above  the  wound,  and  its  ends  fastened  together. 
A  small  block  of  wood,  a  folded  towel,  or  any  substance 
from  which  a  firm  pad  can  be  extemporized,  is  placed  over 
the  artery  and  under  the  handkerchief  encircling  the  limb. 
A  stick  measuring  five  or  six  inches  in  length  is  then  passed 
under  the  handkerchief  at  right  angles,  and  twisted  around 
until  the  pad  compresses  the  artery  firmly.  Turning  the 
stick  draws  the  handkerchief  very  tightly  around  the  limb 
and  over  the  artery,  so  that  it  is  thoroughly  secured. 

Bleeding  from  the  upper  extremity,  at  any  point  below 
the  axilla,  may  be  temporarily  suppressed  by  placing  a  piece 
of  wood  an  inch  and  a  half  or  two  inches  thick  under  the 
arm  at  right  angles  with  the  body,  and  then  pressing  the 
arm  firmly  against  the  chest-walls.  A  large  book  will  an- 
swer the  same  purpose.  In  all  cases  the  material  employed 
must  be  placed  as  high  as  possible  in  the  axilla.  "When  the 
wound  is  situated  below  the  knee-joint,  the  bleeding  may 
be  diminished  by  raising  the  limb  and  placing  it  on  the 
back  of  a  chair,  so  that  pressure  will  be  made  in  the  popli- 
teal space.  The  weight  of  the  limb  in  this  position  is  sufii- 
cient  to  close  the  popliteal  artery.  In  some  cases  it  may 
be  necessary  to  fold  a  towel  and  place  it  behind  the  knee 
between  the  chair  and  the  limb. 

Pressure  may  be  made  in  a  wound  with  the  thumb  and 
fingers,  picked  lint,  compressed  sponge,  or  towels.  In  haem- 
orrhage from  the  carotid  artery,  pressure  may  be  made 
with  the  fingers  along  the  inner  edge  and  lower  half  of  the 
eterno-mastoid  muscle.  The  subclavian  artery  is  compressed 
as  it  passes  over  the  first  rib,  by  pushing  firmly  with  the 
thumb  in  the  subclavian  triangle  behind  the  sterno-mastoid. 


16       EMERGENCIES,  AND  nO«^  TO  TREAT  THEM. 

Pressure  may  be  exerted  on  the  brachial  artery  at  the  inner 
border  of  the  coraco-bracliialis  and  biceps  muscles.  The 
femoral  artery  is  readily  controlled  as  it  passes  under  Pou- 
part's  ligament,  midway  between  the  anterior  superior  spi- 
nous process  of  the  ileum  and  the  pubes.  The  abdominal 
aorta  may  be  compressed  with  the  hand  a  short  distance 
above  and  to  the  left  of  the  umbilicus. 

In  wounds  of  the  palm  of  the  hand,  or  other  places 
where  there  are  many  inosculating  vessels  injured,  it  will 
be  expedient  to  place  a  pad  or  compress  in  the  opening. 
"Whenever  the  bleeding  is  profuse,  and  the  main  artery  can- 
not be  controlled,  it  is  absolutely  necessary  to  stuff  the 
wound  quickly  with  picked  lint  or  other  available  substance. 
It  must  be  filled  up,  packed  tightly,  and  a  bandage  firmly 
applied.  In  the  course  of  a  few  hours  coagula  may  form  in 
the  vessels,  when  the  lint  may  be  removed  and  the  wound 
properly  dressed. 

Cold  is  a  useful  adjunct  in  suppressing  haemorrhage.  It 
is  employed  under  various  forms.  For  moderate  bleeding, 
cloths  wrung  out  of  ice-water  and  placed  over  the  part  will 
answer.  Ice  in  solid  lumps,  or  pounded  and  secured  in  rub- 
ber bags,  or  without  intervening  material,  is  excellent  in 
profuse  haemorrhage.  Cold  produced  by  the  evaporation  of 
ether,  directed  to  the  surface  in  the  form  of  spray,  has  lately 
come  into  use.  Prof.  "William  II.  Thompson,  of  this  city, 
employs  it  with  good  results  in  posPpartum  haemorrhage. 

Cold  acts  by  stimulating  the  arterial  walls  to  contract, 
and  by  assisting  in  the  formation  of  coagula.  Cold  and 
pressure  can  be  used  together. 

Styptics. — Under  this  head  are  included  all  medicinal 
asents  which  control  haemorrhasre.     The  most  efficient  are 


HJilMORRnAGE.  17 

certain  2)reparations  of  iron,  as  the  solution  of  the  per- 
sulphate and  the  sub-sulphate,  commonly  known  as  "  Mon- 
sel's  solution." 

ISTearlj  all  the  vegetable  astringents  belong  to  this  class. 
The  best  are  tannic  or  gallic  acids,  oak-bark,  catechu,  and 
nut-galls.  Preparations  of  alum,  and  common  salt  (chloride  of 
sodium)  are  sometimes  used.  The  iron  and  other  substances 
are  applied  by  means  of  a  camel's-hair  pencil  or  a  sponge. 
They  are  dipped  in  the  solution  and  rubbed  thoroughly  into 
the  wound.  These  agents  act  by  coagulating  the  blood  as 
it  flows  from  the  vessels,  and  by  contracting  the  muscular 
fibres  around  and  in  their  walls.  The  coagula  thus  formed 
should  not  be  removed  until  all  danger  of  a  recurring  hsem 
orrhage  has  passed. 

Torsion  can  be  employed  with  advantage  where  the  ar 
teries  are  small.  This  method  consists  in  seizing  the  bleed 
ing  vessel  with  forceps  and  twisting  it  around  until  a  piece 
is  torn  off,  or  its  orifice  completely  closed.  Some  advocate 
merely  one  or  two  turns  of  the  forceps ;  others  believe  in 
tearing  off  a  portion  of  the  artery. 

LigationvQM^i  be  resorted  to  when  pressure,  styptics,  and 
milder  measures  fail.  The  ligatures  in  general  use  are  silk. 
The  bleeding  vessel  is  first  seized  with  an  artery-forceps,  the 
ligature  passed  around  and  tied.  "When  arteries  of  medium 
size  are  ligated  for  aneurisms,  or  in  wounds,  the  middle  and 
internal  coats  are  cut  through,  and  the  external  wall  brought 
in  contact.  A  clot  forms  on  each  side  of  the  ligature,  per- 
manently closing  the  canal  as  far  as  the  next  collateral 
branch.  When  deep-seated  vessels  are  wounded,  it  is  al- 
ways necessary  to  go  down  in  the  wound  and  tie  above  and 

below  the  opening  in  the  artery,  as  the  lower  is  frequently 
2 


[S      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

tlie  seat  of  secondary  liaiinorrliage  from  collateral  branches. 
Some  advocate  complete  division  of  the  vessel  before  tying, 
if  it  be  only  partially  cut  across.  An  artery  is  tied  in  the 
wound,  because,  in  ligating  at  a  distance  above,  the  bleeding 
might  continue  through  anastomosing  branches  below  the 
ligature.  If  the  wound  is  punctured  and  deep  seated,  it 
must  be  enlarged  to  enable  the  surgeon  to  reach  the  vessel. 
The  wound  at  first  should  only  be  increased  enough  to  allow 
the  operator's  finger  to  enter  and  close  the  bleeding  orifice; 
afterward  it  can  be  enlarged  at  pleasure,  without  danger. 
"When  branches  of  the  external  or  internal  carotids  are 
wounded  through  the  mouth,  it  is  necessary  to  depart  from 
the  rule  of  ligation  in  the  wound,  and  tie  them  in  the  neck. 
{See  article  on  ligation  of  arteries.) 

Acupressure,  as  a  means  of  suppressing  hcemorrhage, 
has  not  been  before  the  profession  a  sufiicicnt  time  to  test 
its  claimed  superiority  over  ligation.  The  method  was  first 
brought  into  notice  by  the  late  Dr.  Simpson,  of  Edinburgh, 
who,  in  adopting  it,  almost  abandoned  the  ligature.  The  canal 
of  the  artery  is  obliterated  by  means  of  a  sharp  needle  in- 
troduced at  one  side  of  the  artery,  and  passed  over  the  vessel 
into  the  tissues  on  the  opposite  side.  Another  method  is  by 
passing  a  common  sewing-needle,  armed  with  fine  wire,  he- 
hind  the  artery,  allowing  the  head  and  point  of  the  needle 
to  be  exposed,  and  then  bringing  the  wire  over  the  tissues 
covering  the  artery  and  fastening  it  to  the  point  of  the 
needle.  In  this  case  the  artery  is  compressed  between  the 
wire  and  needle,  and  not,  as  in  the  former,  by  the  needle 
and  underlying  tissues.  When  acupressure  is  employed 
on  medium-sized  arteries,  the  needle  can  be  removed  in 
three  or  four  hours  with  perfect  safety,  as  by  that  time  a 


HEMORRHAGE.  19 

firm  coagulum  will  lia^e  formed  which  closes  the  canal. 
This  method,  of  course,  will  give  the  wound  a  better  chance 
to  heal,  as  the  ordinary  ligature  is  necessarily  a  source  of 
irritation. 

In  large  vessels,  such  as  the  femoral,  the  needle  must  re- 
main in  for  fifty  or  sixty  hours  at  least,  in  order  to  insure 
success  in  the  operation. 

Cautery. — Tears  prior  to  the  introduction  of  ligation, 
and  before  the  discovery  of  chloroform  and  ether  blessed 
suffering  humanity,  it  was  customary,  after  amputation  of  a 
limb,  to  touch  the  bleeding  stump  with  a  red-hot  iron,  or  to 
plunge  it  into  a  vessel  of  boiling  tar,  to  stop  haemorrhage. 
Happily,  modern  science,  in  its  advances,  has  driven  this 
barbarous  practice  almost  entirely  from  the  profession.  Oc- 
casionally, however,  even  at  this  day,  the  actual  cautery  is 
made  use  of.  Haemorrhage  from  the  neck  of  the  uterus, 
after  removal  of  tumors,  and  from  other  organs  not  accessi- 
ble to  ordinary  means,  can  be  thoroughly  controlled  by  the 
hot  iron. 

Position. — When  the  bleeding  is  moderate,  simple  eleva- 
tion of  the  wounded  limb  will  retard  the  current  coming 
from  the  heart,  and  thus  assist  in  stopping  the  flow.  It  is 
always  to  be  employed  in  conjunction  with  other  measures 
previously  mentioned. 

After  the  cessation  of  the  hemorrhage,  the  lost  vitality 
of  the  patient  must  be  restored.  Bottles  filled  with  hot 
water  are  to  be  applied  to  the  extremities,  and  the  body  is 
covered  with  warm  blankets.  Tablespoon  ful-doses  of  brandy 
and  a  few  drops  of  ammonia  should  be  administered  every 
fifteen  or  twenty  minutes,  or  at  such  intervals  as  the  case 
may  require,  until  reaction  is  thoroughly  established.     Sul> 


20       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

sequent  irritabilitv  of  the  nervous  system  is  to  be  treated 
W'itli  opiates. 

"Wlien  the  loss  of  blood  is  so  great  tbat  reaction  is  im- 
possible tbrougli  the  ordinary  methods,  resort  must  be  had 
to  transfusion.  This  operation  consists  in  abstracting  blood 
from  a  robust  man  or  woman,  and  injecting  it  into  the  veins 
of  the  exsanguinated  patient.  If  an  apparatus  for  the  pur- 
pose is  not  at  hand,  or  its  use  but  little  understood,  a  com- 
mon hard-rubber  syringe,  with  a  capacity  of  five  or  six 
ounces,  will  answer.  An  opening  is  made  in  one  of  the  veins 
of  the  forearm,  and  into  this  a  canula,  adapted  to  the  point 
of  the  syringe,  is  inserted.  A  bandage  tied  below  the  in- 
cision prevents  further  bleeding.  The  syringe,  warmed  and 
charged  with  the  fresh  bloo.d,  is  introduced,  and  tlie  piston 
steadily  forced  down  until  the  instrument  is  emptied.  From 
ten  to  twenty  ounces  may  be  injected  at  one  sitting,  and  the 
operation  may  be  repeated  if  necessary.  Care  must  be  taken 
to  force  out  all  air  from  the  syringe  before  it  is  used.  The 
efficacy  of  this  operation  has  been  fully  proved.  Patients 
have  been  restored  to  life  under  circumstances  which  were 
such  as  to  almost  preclude  the  hope  of  recovery. 

I  have  lately  employed  a  modification  of  Dieulafoy's 
aspirator  in  transfusion.  The  arm  is  bandaged  as  in  the 
ordinary  method  for  venesection,  and  a  needle  of  the  aspi- 
rator inserted  into  the  distended  median  basilic  vein.  The 
stop-cock  of  the  aspirator  is  then  turned,  and  the  blood 
rushes  in  and  fills  up  the  cylinder.  A  vein  in  the  patient's 
arm  having  been  exposed,  and  an  opening  made  in  it  for  the 
insertion  of  a  canula,  the  tube  from  the  opposite  side  of  the 
aspirator  is  attached,  and  the  blood  forced  through  it  into 
the  vein.     See  Appendix. 


CHAPTER  II. 

EJEMOBRHA  (?^— (Continued). 

Bleeding  from  the  Nose,  Mouth,  Lungs,  Stomach,  Intestines,  Kidneys,  Ureters, 
Bladder,  Urethra.— Ecohymosis. 

Epistaxis,  or  bleeding  from  the  nasal  passages,  is  the 
most  frequent  and  least  dangerous  of  all  internal  haemor- 
rhages. It  occurs  generally  from  one  nostril.  Repeated 
haemorrhage  from  the  left  nostril  is  said  to  be  a  certain  indi- 
cation of  splenic  disease. 

Some  of  the  capillary  vessels  of  the  nasal  mucous  mem- 
brane communicate  directly  with  those  of  the  cranial  cavity, 
and,  when  epistaxis  appears  during  congestion  of  the  brain, 
its  action  is  decidedly  beneficial  in  diminishing  the  quantity 
of  blood  in  that  organ.  In  inflammations  of  the  mucous 
membrane,  a  rupture  of  the  distended  and  engorged  capil- 
laries may  be  the  commencement  of  a  healthy  action.  All 
cases  of  epistaxis,  however,  are  not  attended  with  the  same 
good  results :  the  bleeding  may  be  so  persistent  as  to  seri- 
ously endanger  life. 

The  ancients  considered  bleeding  from  the  nose  as  an 
indication  of  fever,  and  bled  and  purged  the  unfortunate 
patient  while  any  trace  of  the  disorder  remained.  The 
blood  was  supposed  to  be  overheated,  and  in  a  state  of 
ebullition,  which  rendered  its  removal  necessary. 


22       EMERGENCIES,  AND  BOW  TO  TREAT  THEM. 

The  causes  of  epistaxis  are  violent  exercise  after  drink- 
ing, laceration  of  yessels  by  blows  or  falls,  cardiac  disease, 
catarrhal  inflammations,  congestion  of  the  brain,  syphilitic 
or  scrofulous  ulceration,  the  hajmorrhagic  diathesis  and 
disordered  conditions  of  the  blood,  such  as  occur  in  scor- 
butis,  purpura,  and  continued  fevers. 

Severe  forms  of  epistaxis  are  preceded  by  a  feeling  of 
weight,  and  fulness  about  the  forehead,  with  pain  and  ver- 
tigo. 

Treatment. — First  ascertain  whether  the  blood  escapes 
fi'om  both  nostrils,  or  from  the  right  or  left ;  then,  on  the 
affected  side,  raise  the  arm  above  the  head,  and  grasp  the 
nose  with  a  firm  pressure  between  the  thumb  and  forefinger; 
at  the  same  time,  a  towel  saturated  with  ice- water  may  be 
laid  on  the  forehead.  The  arm  is  raised  to  distribute  the 
force  of  the  heart's  action,  and  to  take  the  pressure  off  the 
carotid  vessels,  diminishing  the  strength  of  the  current 
through  them. 

Some  advise  the  application  of  ice  to  the  mammas  of  the 
female  and  testes  in  the  male,  or  simply  placing  the  hands 
in  cold  water.  When  pressure,  raising  the  arm,  or  cold 
applications,  are  unsuccessful,  styptics  may  be  resorted  to. 
Inject  with  a  syi'inge  a  quantity  of  ice-water,  or  a  solution 
of  common  salt,  in  the  proportion  of  one  tablespoonful  to 
half  a  tumber  of  water ;  or  some  of  the  preparations  of  iron, 
such  as  solutions  of  the  pernitrate  or  persulphate.  The 
iron  may  be  thrown  up  the  nostril,  either  diluted  or  not,  or 
a  piece  of  lint,  twisted  and  moistened  with  the  solution,  may 
be  forced  up  the  canal  and  allowed  to  remain  until  the 
bleeding  ceases.  "When  the  blood  comes  from  laceration  of 
the  naso-palatine  artery,  all  these  measures  are  apt  to  fail. 


n^MORRHAGE.  23 

and  the  posterior  nares  must  then  be  plugged.  Tlie  opera- 
tion of  plugging  is  simple,  and  does  not  require  a  great 
amount  of  skill.  It  may  be  performed  with  Beloc's  canula 
or  a  gum-elastic  catheter  (ISTo.  4  or  5  will  do).  Through 
the  eye  of  the  instrument  pass  a  string,  allowing  the  ends 
to  hang  down. 

Introduce  the  catheter  through  the  nostril  into  the 
mouth,  and  draw  the  string,  which  is  hanging  from  its  end, 
out  beyond  the  lips.  To  this  attach  a  piece  of  sponge  suf- 
ficiently large  to  fill  up  the  opening  in  the  posterior  nares. 
Then  withdraw  the  catheter  from  the  nose,  and  make  trac- 
tion on  the  string  until  the  sponge  is  drawn  back  into  the 
posterior  nares,  completely  filling  its  cavity.  If  necessary, 
the  sponge  may  be  dipped  in  an  astringent  solution  before 
its  introduction.  This  method  scarcely  ever  fails  to  control 
the  most  obstinate  hsemorrhage. 

Stomatoeehagia. — Haemorrhage  from  the  mouth.  This 
variety  needs  scarcely  more  than  a  passing  notice.  It  re- 
quires special  treatment  only  when  occurring  in  persons 
with  the  hsemorrhagic  diathesis.  Inflammation  of  the  buc- 
cal cavity,  ulcers,  and  injuries,  are  its  principal  causes. 
Einsing  the  mouth  with  alum-water,  or  some  other  astrin- 
gent preparation,  will  check  it  effectually. 

H^MATEMESis. — Hsemorrhagc  from  the  stomach  generallj 
occurs  during  the  progress  of  some  chronic  disease  of  the 
liver,  portal  system,  or  stomach.  Any  obstruction  to  the 
return  of  blood  through  the  portal  vein,  such  as  exists  in 
the  dram-drinker's  liver  {cirrhosis),  in  inflammation  or 
thrombosis  of  the  vein,  will  occasion  it.  Chronic  ulcer  and 
cancer  of  the  stomach,  gastritis,  and  corrosive  poisons,  are 
rdso  prolific  causes. 


24:  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

In  cirrhosis,  the  liver  is  diminished  in  size  bj  the  con- 
traction of  newjihrous  tissue,  ■u'hich  is  formed  throughout 
the  organ  during  the  inflammatory  process.  This  new  tissue 
is  either  developed  from  inflammatory  lymph  {Rol:ltamhy)^ 
u^or  by  the  proliferation  of  connective-tissue  cells  {Yirchow). 
It  is  located  principally  around  the  hepatic  vessels.  By  its 
contraction,  the  ramifications  of  the  portal  vein  are  pressed 
upon,  and  their  capacity  diminished  or  destroyed,  and  the 
result  is  a  damming  back  of  the  blood  in  the  stomach  and 
intestines.  In  a  short  time  the  distention  is  greater  than  the 
walls  of  the  vessels  can  resist,  and  consequently  they  are 
ruptured.  Coagulation  of  blood  in  the  veins  (thrombosis), 
with  or  without  inflammation,  produces  ha^matemcsis  in  a 
similar  way. 

In  chronic  ulcer  and  cancer,  molecular  death  of  the  tis- 
sue proceeds  gradually,  until  the  capillary  walls  are  reached 
and  perforated.  If  a  large  vessel  have  been  opened,  the 
bleeding  may  cause  death  in  a  short  period ;  but  such  an 
event  rarely  happens. 

Instances  are  recorded  of  hoemorrhage  from  the  stomach 
occurring  at  the  menstrual  period.  In  this  vicarious  men- 
struation, the  usual  flow  from  the  uterus  is  absent. 

In  profuse  haemorrhage  from  tlie  stomach,  the  patient  will 
have  a  feeling  of  fulness  and  oppression  in  tlie  epigastrium. 
The  countenance  becomes  pallid ;  there  are  vertigo  and 
dimness  of  vision ;  and  finally  a  fluid,  which  imparts  a  warm 
sensation  to  the  oesophagus,  is  vomited.  If  the  blood  have 
been  extravasated  suddenly  and  in  an  empty  stomach,  there 
will  be  little  change  in  its  physical  or  chemical  characteris- 
tics. But  if  slowly  exuded,  and  allowed  to  mingle  with  the 
gastric  juice,  or  partially-digested  food,  it  takes  on  a  dark 


HEMORRHAGE.  25 

color  resembling  "  coffee-grounds."  The  normal  alkaline 
reaction  is  changed  to  acid,  and  the  blood  will  not  coagu- 
late. These  peculiarities  are  usually  present,  and  in  cirrho- 
sis they  are  particularly  marked.  Blood  from  wounds  of 
the  mouth  is  sometimes  swallowed  and  afterward  thrown 
up,  but  a  careful  examination  will  reveal  the  source,  and 
prevent  an  erroneous  diagnosis. 

Tlie  act  of  vomiting,  which  forces  out  the  blood  in 
haematemesis,  is  seldom  attended  with  nausea.  In  passing 
out  some  may  enter  the  larynx  and  induce  a  fit  of  coughing, 
thereby  leading  to  the  supposition  that  the  blood  is  from 
the  lungs,  instead  of  the  stomach.  On  the  other  hand,  a 
paroxysm  of  coughing,  with  haemorrhage  from  the  lungs, 
may  bring  on  nausea  and  vomiting,  and  cause  the  physician 
to  locate  the  disorder  in  the  stomach.  It  is  necessary,  there- 
fore, in  making  a  diagnosis,  to  exercise  care  and  judgment. 

It  is  well  to  remember  that  blood  from  the  stomach  is 
generally  dark  in  color,  mixed  with  food,  and  is  acid  in  re- 
action. If  coagula  are  present,  they  will  be  found  black  and 
heavy,  from  absence  of  air.  There  will  be  a  previous  history 
of  pain,  nausea,  vomiting,  and  a  disordered  stomach,  with 
the  special  symptoms  of  the  disease  which  may  have  occa- 
sioned the  hsematemesis. 

In  haemorrhage  from  the  lungs,  the  blood  is  generally 
bright  red,  frothy,  mixed  with  bubbles  of  air,  and  alkaline 
in  reaction.  A  fit  of  coughing  precedes  and  accompanies 
the  bleeding.  There  are  pain  in  the  chest,  and  signs  of  tu- 
berculosis or  other  affection  of  the  lungs  or  cardiac  disease, 
and  there  is  no  history  of  disease  of  the  liver  or  stomach. 
Moist  rdles  can  be  heard  on  auscultation,  near  the  seat  of  the 
pain,  and  there  may  also  be  slight  dulness  on  percussion. 


26      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

In  all  doubtful  cases,  the  mouth  and  fauces  should  undergo 
a  careful  examination.  Iliemorrhage  from  these  parts  is 
often  mistaken  for  hogmatemesis.  A  perfect  knowledge  of 
these  points  of  difference,  and  their  careful  investigation  at 
the  bedside,  will  make  the  diagnosis  a  matter  of  almost 
positive  certainty. 

Treatment. — Absolute  rest  in  the  recumbent  posture 
must  be  rigidly  enforced  in  this  and  every  other  variety  of 
internal  hajmorrhage.  The  patient's  room  must  be  kept 
free  from  visitors,  and  only  the  nurse  and  doctor  arc  to  be 
admitted.  Every  source  of  excitement  must  be  removed. 
These  stringent  preliminaries  are,  of  course,  only  required 
when  much  blood  has  been  lost.  There  are  many  mild  cases 
in  which  they  are  not  called  for.  Ice  stands  at  the  head  of 
all  remedial  agents  for  the  suppression  of  hsematemesis.  It 
can  be  administered  continuously  in  small  pieces,  or  at  dif- 
ferent intervals,  as  the  case  may  demand.  Cloths  wet  with 
ice-water,  or  pounded  ice  in  bags,  may  also  be  applied  over 
the  epigastrium.  Ether-spray,  directed  over  the  stomach, 
produces  intense  cold,  and  is  worthy  of  trial.  Of  the  various 
styptics  employed,  some  prefer  the  following : 

^.   Liquor,  ferrisubsulphatis 3i. 

Aquae |  ii.    M. 

One  teaspoonful  of  this  solution  is  to  be  given  every  half 
hour,  or  more  frequently  if  required.  Other  preparations 
of  iron  are  also  used.  Some  prefer  the  acetate  of  lead  in 
one  or  two  grain  doses.  Alum,  creosote,  tannic  and  gallic 
acids,  answer  in  some  cases. 

■  All  the  solutions  employed  should  be  kept  on  ice,  and 
given  in  small  quantities,  as  they  are  apt  to  be  thrown  up. 


H^MORRHA-GE.  27 

If  vomiting  is  produced  by  one  preparation,  let  something 
else  be  substituted.  The  contractions  of  the  stomach  in  the 
act  of  vomiting  increase  haemorrhage. 

The  subsequent  treatment  must  depend  entirely  on  the 
accompanying  disease  and  the  amount  of  blood  lost.  !N"u- 
tritious  diet  and  tonics  are  indicated  to  restore  the  lost  vi- 
tality. "When  strength  is  regained,  the  disease  which  pro- 
duced the  haemorrhage  should  receive  special  attention.  If 
the  bleeding  has  been  so  great  as  to  induce  collapse,  rapid 
stimulation  should  be  resorted  to  in  the  manner  described  in 
the  preceding  chapter. 

Meloena-  is  a  term  usually  employed  to  denote  haemor- 
rhage from  the  bowels,  although  any  dark-colored  discharge 
from  the  same  parts  might  properly  be  classed  under  the 
same  head.  Melsena  is  caused  by  many  of  the  same  disor- 
ders which  occasion  hsematemesis.  The  portal  venous  sys- 
tem, which  carries  blood  from  the  stomach,  also  takes  it  from 
the  intestines.  Any  abnormal  condition,  therefore,  which 
obstructs  the  circulation  through  the  portal  vein,  such  as 
those  previously  mentioned,  is  liable  to  produce  extravasa- 
tion, of  blood  in  any  part  of  the  stomach  or  intestinal  canal. 
Sometimes  the  blood  which  is  poured  out  in  the  stomach 
passes  through  the  pyloric  orifice,  and  is  voided  by  the  bow- 
els instead  of  being  vomited. 

Among  other  causes  of  bleeding  from  the  intestines  may 
be  enumerated  ulceration  of  the  mucous  coat,  from  chronic 
or  acute  inflammations,  and  rupture  of  capillary  vessels  dur- 
ing inflammatory  congestion,  as  in  dysentery  and  enteritis. 
HcBmorrhoids,  or  piles,  are  also  classed  as  common  causes. 
In  low  forms  of  fever,  such  as  typhoid  or  yellow  fever,  haem- 
orrhage from  the  bowels  is  not  of  infrequent  occurrence.    In 


28  EJIERGENCIES,  AND  HOW  TO  TREAT  THEM. 

the  fii'st  instance,  it  is  due  to  ulceration ;  in  the  second,  it 
arises  from  rupture  of  blood-vessels. 

"When  the  blood  proceeds  from  the  upper  part  of  the  in- 
testinal canal,  or  when  it  is  poured  out  in  small  quantities, 
it  appears  in  dark  masses  resembling  tar.  In  profuse  haem- 
orrhage it  has  the  same  characteristics  as  when  occurring 
from  other  organs.  When  the  bleeding  is  due  to  ulceration, 
the  blood  is  generally  redder  than  in  rupture  of  portal  capil- 
laries or  in  piles.  Haemorrhage  from  intestinal  haemorrhoids 
(piles)  occurs  more  frequently  than  any  other  variety.  In  cir- 
rhosis of  the  liver,  the  gastric  vessels  are,  as  a  rule,  first  rup- 
tured, and  afterward  the  vessels  farther  down  the  canal.  Oc- 
casionally, cases  of  violent  haemorrhage  from  the  bowels,  due 
to  cirrhosis,  prove  fatal  in  a  few  moments.  Plethoric  per- 
sons, M'ho  feed  on  the  fat  of  the  land,  and  indulge  freely  in 
wine,  are  at  times  subject  to  small  haemorrhages  while 
straining  at  stool.  The  portal  venous  system  contains  a 
much  larger  proportion  of  fluid  during  digestion  than  at 
any  other  period,  and  in  plethoric  men  this  distention 
reaches  its  maximum,  so  that,  in  a  violent  effort  to  evacuate 
the  bowels,  some  of  the  engorged  capillaries  rupture  and 
relieve  themselves.  This  variety  of  melaena  occurs  inde- 
pendent of  any  organic  disease,  not  even  haemorrhoids  being 
present  to  account  for  it.  Haemorrhage  of  this  character 
acts  as  a  safety-valve,  and  should  be  let  alone  unless  too 
profuse. 

Treatment. — The  general  rules  which  govern  the  treat- 
ment of  other  varieties  of  haemorrhage  must  be  followed 
here ;  perfect  rest  and  quiet  secured,  and  every  excitement 
avoided.  Cold  water  poured  slowly  from  a  sprinkler  or 
pitcher  is  advisable  in  alarming  cases.     Cloths  wet  with  ice- 


HiEMORRnAGE.  29 

water,  or  injections  of  ice-water,  or  of  pounded  ice,  into  the 
rectum,  are  beneficial.  The  vegetable  astringents,  such  as 
logwood,  oak-bark,  catechu,  tannic  and  gallic  acids,  given 
by  the  mouth  or  rectum,  act  well  in  mild  forms  of  haemor- 
rhage. Some  prefer  the  styptic  solutions  of  iron,  men- 
tioned in  the  treatment  of  hsematemesis.  Small  doses  of 
opium,  to  diminish  peristaltic  action  of  the  intestines,  should 
always  be  given.  I  have  found  tannic  acid  and  opium,  ad- 
ministered by  the  mouth,  and  the  apj)lication  of  cold  water 
to  the  abdominal  walls,  answer  admirably  in  ordinary  cases 
of  melsena. 

HiEMOPTTSis. — The  occurrence  of  haemorrhage  from  the 
lungs  was  at  one  time  considered  a  certain  indication  of 
tubercular  deposit.  It  was  a  sign,  of  fatal  significance  in  the 
eyes  of  physician  and  patient.  A  closer  investigation  of 
pathological  changes  in  the  lung-tissue  has  demonstrated 
conclusively  the  erroneousness  of  this  idea.  Haemoptysis 
is  found,  in  the  majority  of  cases,  to  depend  on  conditions 
which  do  not  seriously  endanger  life,  and  which,  are  amen- 
able to  treatment. 

The  class  of  persons  most  subject  to  this  hsemorrhage  are 
those  who  grow  rapidly  in  height,  without  a  corresponding 
development  in  bulk,  who  are  pale  and  delicate,  and  subject 
to  common  colds  and  scrofulous  inflammations.  In  these 
cases  there  is  a  general  lax  condition  of  the  system,  a  want 
of  tonicity  in  the  capillary  vessels,  and  in  other  tissues 
throughout  the  body,  which  predispose  to  haemorrhage.  In 
inflammation  of  the  larynx,  trachea,  or  bronchial  tubes,  the 
vessels  of  the  mucous  membrane  are  distended  with  blood. 
A  i>aroxysm  of  coughing  increases  the  internal  pressure  on 
these  vessels  to  such  an  extent  that  they  rupture,  and  blood 


30      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

appears  in  the  expectorated  fluid.  The  amount  of  blood 
poured  out  will  of  course  depend  on  the  size  and  number  of 
the  ruptured  capillaries.  In  all  cases  of  catarrhal  inflamma 
tions  of  the  air-passages  this  rupture  and  extravasation  are  li- 
able to  occui',  independently  of  other  affections.  If  the  blood 
were  expectorated,  the  haemorrhage  would  be  rather  a  bene- 
fit than  otherwise;  but  sometimes  it  remains  in  the  smaller 
tubes  and  air-cells,  acts  as  an  irritant,  sets  up  inflammation, 
and  finallj  may  go  on  to  consolidation  and  subsequent  soft- 
ening and  degeneration  of  the  lung-tissue  {Niemeyer). 

Organic  disease  of  the  heart  is  accompanied  by  haemop- 
tysis. "Wlien  insufficiency  of  the  mitral  valve  exists,  the 
blood  regurgitates  into  the  left  auricle,  which  is  therefore 
partially  filled  with  blood  that  should  have  remained  in  the 
ventricle.  Tins  causes  a  damming  back,  or  obstruction,  to 
the  blood  coming  from  the  four  pulmonary  veins  to  the 
auricle,  and  consequent  congestion  of  the  lungs.  The  caj^il- 
lary  vessels  in  the  bronchial  tubes,  and  in  other  parts,  are 
distended,  and  relieve  themselves  by  rupture. 

Sometimes,  in  these  cases,  large  extravasations  of  blood 
occur  in  the  parenchyma  of  the  lung  {jpiilmonary  a^pojplexy), 
lacerating  and  destroying  its  substance,  and  hastening  a 
fatal  termination.  Extravasations  of  blood  in  cardiac  dis- 
ease are  also  due  to  another  cause,  viz.,  the  plugging  of 
small  arterial  capillaries  by  clots  of  fibrine  detached  from 
the  right  side  of  the  heart.  These  clots  are  carried  into  the 
pulmonary  artery,  blocking  up  some  of  its  terminal  branches. 
This  obstruction  necessarily  diminishes  the  current  in  the 
capillaries  supplied  by  the  plugged  vessel ;  they  become 
crowded,  choked  up  with  blood,  the  internal  pressure  soon 
forces  their  thin  walls  to  give  way,  and  the  blood  is  extrava- 


HEMORRHAGE.  31 

Bated  into  tlie  air-cells,  terminal  bronchi,  and  between  the 
elastic  fibres  of  the  cells.  These  clots,  after  coagulation,  are 
circumscribed,  sharply  defined,  and  dark  in  color.  To  this 
old  condition  a  new  name  has  been  given,  viz.,  hoBmorrhagic 
infarction,  to  distinguish  it  from  another  variety  of  pul- 
monary apoplexy  in  which  the  clot  is  diffused,  and  lung- 
tissue  destroyed. 

Tubercular  deposit  induces,  haemoptysis  in  one  of  three 
ways :  1.  By  mechanical  pressure  it  may  obstruct  the  small 
attenuated  vessels  so  as  to  cause  rupture ;  2.  It  may  create 
inflammatory  congestion,  which  is  relieved  by  the  walls 
giving  way ;  or,  3.  The  softening  and  degeneration  of  tissue 
which  accompany  the  second  and  third  stages  of  tuberculosis, 
involve  the  capillaries,  destroy  them,  and  haemorrhage  is  the 
result. 

Gangrene  of  the  lung  is  seldom  accompanied  by  haemop- 
tysis. When  present,  it  is  due  to  the  morbid  process  in- 
cluding the  vessels  in  the  general  destruction. 

The  haemoptysis  which  occasions  the  characteristic  rust- 
colored  sputa  of  pneumonia  either  arises  from  laceration  of 
the  minute  capillaries,  or  by  the  passage  of  the  red  globules 
through  the  wall  of  the  vessel  without  ruptm-e.  The  latter 
process  is  doubtful,  to  say  the  least  of  it. 

The  inhalation  of  chlorine  gas,  sulphuretted  hydrogen, 
and  other  irritating  substances,  likewise  occasions  haemop 
tysis.  Wounds  of  the  lung  are  always  attended  by  more 
or  less  expectoration  of  blood. 

One  curious  and  rare  variety  of  haemoptysis  is  that  which 
occurs  at  the  menstrual  period,  when  the  discharge  of  blood 
from  the  uterus  is  absent.  There  are  but  few  cases  on 
record.     Dr.  "Watson  relates  one  of  a  young  girl  who  men- 


32  EMERGENCIES,  AND  EOW  TO  TREAT  THEM. 

Btruated  once  naturally  at  sixteen  years  of  age,  and,  from 
that  time  until  the  age  of  fifty,  she  suffered  from  hiBmop- 
tysis  regularly  once  each  month.  Accompanying  the  loss  of 
blood  were  the  usual  uneasy  sensations  of  pain  in  the  pelvis 
and  general  malaise. 

In  slight  cases  of  haemoptysis  the  patient  has  first  a  tick- 
ling sensation,  beneath  the  sternum,  which  compels  him  to 
cough.  The  effort  brings  up  a  warm  fluid  having  a  pecu- 
liar sweetish  taste,  which  when  expectorated  is  found  to  be 
blood.  It  is  generally  bright  red,  and  filled  with  bubbles 
of  air.  At  other  times  the  sputa  for  some  days  are  simply 
tinged  or  streaked  with  red.  In  more  serious  cases,  and 
especially  in  heart-disease,  there  is  a  sharp,  intense  j)ain  in 
some  part  of  the  chest,  followed  immediately  by  excessive 
dyspnoea,  and  the  expectoration  of  large  quantities  of  blood. 
This  blood  is  not  so  bright  as  in  the  former  instance,  but  it 
still  contains  air.  On  auscultation  near  the  seat  of  extrava- 
sation, moist  rdles,  and  occasionally  bronchial  breathing,  can 
be  heard.  The  rales  are  more  liquid  in  character  than  those 
produced  by  mucus.  There  is  more  or  less  dulness  on  per- 
cussion, in  the  majority  of  cases.  These  large  extrayasations 
are  usually  followed  by  pneumonia.  Its  advent  is  easily 
recognized  by  the  characteristic  physical  signs,  and  by  the 
increased  temperature,  rapid  pulse,  and  other  evidences  of 
febrile  excitement. 

In  examining  a  case  of  supposed  haemoptysis,  it  is  well 
always  to  take  into  consideration  the  fears  of  the  patient, 
when  determining  the  quantity  of  blood  lost.  The  fright 
causes  the  amount  to  be  greatly  exaggerated.  Investigate 
carefully  the  condition  of  the  nose,  mouth,  and  fauces.  Blood 
from  these  parts  may  get  into  the  larynx,  excite  coughing, 


HiEMORRnAGE.  33 

and  be  expectorated,  thus  leading  to  an  erroneous  diagnosis. 
The  differentiation  between  haemoptysis  and  hseraatemesis  ia 
readily  made.  In  the  latter  the  blood  is  dark-colored,  acid 
in  reaction,  uncoagulable,  does  not  contain  air,  and  is  ex- 
pelled by  the  act  of  vomiting.  "With  it  there  is  a  history  of 
some  disorder  of  the  stomach  or  liver.  In  the  former 
the  blood  as  a  rule  is  red — it  is  alkaline  in  reaction,  coagu- 
lable,  filled  with  bubbles  of  air,  is  brought  up  by  coughing, 
and  there  is  a  previous  history  of  some  variety  of  lung- 
disease  {see  Hsematemesis). 

Treatment. — The  patient  should  be  placed  in  a  sitting 
posture  in  bed,  propped  up  with  pillows.  A  cool  room  is 
desirable.  Every  cause  of  excitement  must  be  removed. 
The  variety  of  medication  demanded  depends  to  a  certain 
extent  on  the  cause  of  the  hasmorrhage.  If  it  be  due  to 
cardiac  disease,  and  if  the  heart's  movements  be  accelerated, 
it  will,  of  course,  be  expedient  to  administer  an  arterial 
sedative  in  conjunction  with  the  astringent.  For  this  pur- 
pose the  following  prescription  will  be  found  of  service  : 

5.  Ext.  verat.  viridis 3.3  83. 

Ext.  ergots fl.  3  ij. 

Acidi  sulph.  aromat 3ij. 

Aquae fl.  I  ij.    M. 

Administered  in  30-drop  doses,  largely  diluted,  every  half- 
hour,  until  the  desired  effect  is  produced.  Digitalis  may  be 
substituted  for  veratrum,  or  given  separately.  Great  care 
must  be  exercised  in  its  administration.  For  the  urgent 
dyspnoea,  which  also  accompanies  this  haemorrhage  in  heart- 
disease,  the  application  of  half  a  dozen  dry  cups  to  the 
thorax  will  be  found  an  admirable  remedy.     They  relieve 


34:      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

the  troublesome  shortness  of  breath,  and,  by  drawing  blood 
to  the  surface,  duninish  the  congestion  of  the  lun<rs. 

If  there  be  no  special  contraindication,  the  following 
preparation  of  sugar  of  lead  and  opium,  although  incom- 
patible, will  often  answer  the  purpose  : 

5.   Plumbi  acetati3 39. 

Pulv.  opii gr.  ij.    M. 

Make  ten  pills.  One  to  be  given  every  half-hour.  In  sim- 
ple cases,  one  of  the  oldest,  and,  at  the  same  time,  one  of 
the  best,  remedies  is  common  salt,  alone  or  with  vinegar. 
Half  a  teaspoonful  can  be  given  at  intervals  of  fifteen  min- 
utes until  the  hsemorrhage  is  controlled. 

5.   Acidi  sulph,  dil fl- 3  ij. 

Aluminis 3j, 

Aquaa fl.  |  ij.    M. 

Can  be  taken  in  teaspoonful  doses  every  half-hour.  Some 
prefer  the  preparations  of  iron.  Inhalation  of  the  vapor  of 
tr.  ferri  chloridi  has  been  recommended,  but  its  irritating 
properties  would  tend  to  excite  coughing,  and  therefore 
should  not  be  employed.  Gallic  acid  in  three-grain  doses, 
and  other  vegetable  astringents,  are  found  efficacious.  In 
connection  with  the  internal  remedies  mentioned,  hot  ap- 
plications to  the  dorsal  region  of  the  spinal  column,  and 
cold  ones  in  front,  will  be  of  service.  When  all  danger 
from  loss  of  blood  has  passed  away,  the  disease  which  pro- 
duced it,  and  the  inflammation  (if  any)  which  follows, 
should  receive  careful  attention. 

H.EMATUKiA. — Blood  in  the  urine  is  a  symptom  of  many 
varied  pathological   conditions   distinct  in  character  and  in 


HAEMORRHAGE.  35 

location.  Ilaving  its  origin  in  different  organs  some  consid- 
erable distance  apart,  a  correct  appreciation  of  its  source  is 
attended  with  greater  difficulty  than  are  heemorrhages  from 
the  viscera.  Lesions  in  any  part  of  the  genito-urinary  tract 
from  the  kidneys,  ureter,  bladder,  prostate  gland,  or  ure- 
thra, may  bring  on  hsematuria. 

Constitutional  blood-diseases,  as  purpura,  scurvy,  ty- 
phus or  yellow  fever,  are  classed  as  causes  independent  of 
special  disorders  in  the  organs  mentioned. 

Haemorrhage  from  the  kidneys  arises  from  external  vio- 
lence, inflammation  of  the  tubes  or  parenchyma  of  the 
organ  ;  the  passage  of  renal  calculi,  or  ulceration  resulting 
from  the  infarction  of  these  bodies,  in  or  near  the  pelvis. 
The  passage  of  large  calculi  through  the  ureter  tears  the 
mucous  membrane,  and  bleeding  results. 

Blood  is  found  in  the  urine  in  injuries  of  the  bladder 
from  introduction  of  instruments  or  blows  on  the  hypogas- 
trium,  acute  cystitis,  fungous  degeneration  of  the  mucous 
membrane,  and  cancerous  disease  of  the  organ.  Urethri- 
tis, chordae,  and  injuries  of  various  kinds,  are  prolific 
causes  of  haemorrhage  from  the  urethra.  Yarious  medici- 
nal agents,  such  as  cantharides,  turpentine,  etc.,  etc.,  given 
in  overdoses,  produce  excessive  congestion  in  the  genito- 
urinary tract  which  is  often  accompanied  by  hsematm-ia. 

"When  called  to  a  case  of  supposed  haematuria,  it  will  be 
well  first  to  determine  whether  blood  is  present  in  the  urine 
or  not,  and  then  endeavor  to  discover  its  source.  Healthy 
urine  is  a  clear  "  amber-colored  fluid,"  acid  in  reaction,  and 
having  a  specific  gravity  ranging  from  1.118  to  1.125. 
Urine  which  contains  blood  has  a  smoky  tint,  if  the  quan- 
tity be  small ;  dark  red  or  chocolate-brown,  when  the  quan- 


36       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

titj  is  large.  The  reaction  in  most  cases  is  alkaline,  and.  the 
specific  gravity  is  increased.  On  being  allowed  to  stand,  a 
dark-reddish  mass  sinks  to  the  bottom,  while  the  superna- 
tant fluid  still  maintains,  to  a  certain  extent,  its  smoky 
hue.  Heating  the  liquid  will  give  a  cloudy  precipitate  of 
albumen,  tinged  M'ith  the  coloring  matters  of  the  blood, 
while  the  rest  of  the  urine  remains  clear.  The  surest 
method  of  diagnosis  is  by  microscopical  examination. 
Blood-corpuscles  are  recognized  by  their  "yellow  color, 
uniform  size  and  non-granular  surface  "  {Bird). 

There  are  many  substances  besides  blood  which  give  a 
reddish  color  to  the  urine.  An  excess  of  urates  in  other- 
wise normal  urine  will  induce  a  red  or  brown  deposit  when 
the  liquid  cools.  To  determine  their  presence  apply  heat, 
and  the  urine  will  resume  its  natural  transparency. 

The  use  of  beet-root,  madder,  logwood,  etc.,  also  occa- 
sions a  red  color.  The  applications  of  heat  in  these  cases 
will  not  produce  a  precipitate,  showing  that  the  tinge  is  not 
due  to  blood. 

"Wlien  the  blood  x>i*oceeds  from  the  kidneys,  it  will  be, 
generally,  diffused  throughout  the  urine.  It  will  be  attend- 
ed with  a  history  of  injury,  the  passage  of  a  calculus,  or 
signs  of  nephritic  inflammation.  A  microscopical  investi- 
gation will  show  small  blood-casts  of  the  uriniferous  tubules, 
red  globules,  and  epithelium  from  the  pelvis  of  the  kidney. 
If  the  blood  come  from  the  commencement  of  the  ureter, 
small  plugs  of  fibrine,  resembling  maggots,  may  sometimes 
be  seen  in  the  bottom  of  the  glass. 

In  haemorrhage  from  the  bladder,  more  blood  comes 
away  at  the  end  of  micturition  than  during  the  act ;  it  is 
clotted,  and  not  diffused  through  the  liquid,  as  in  the  former 


HEMORRHAGE.  37 

instance.  There  is  a  liistorj  of  injury,  signs  of  cystitis, 
Bucli  as  frequent  desire  to  micturate,  pain  during  tLe  act, 
and  pain  on  pressure  over  the  pubes,  or  signs  of  stone. 

When  the  bleeding  takes  place  from  the  urethra,  the 
blood  precedes  the  stream  of  urine.  There  is  one  exception 
to  this  rule,  namely,  where  partially-healed  ulcers  exist  in 
the  canal.  The  contraction  of  the  urethral  walls,  as  the  last 
drops  of  urine  pass  out,  lacerates  some  of  the  delicate  vessels 
in  the  ulcer.   I  have  known  this  to  occur  in  several  instances. 

A  careful  consideration  of  the  foregoing  points  of  differ- 
ence will,  in  most  cases,  enable  the  practitioner  to  make  a 
correct  diagnosis. 

Treatment. — "When  injury  or  disease  of  the  kidney 
causes  haemorrhage,  little  treatment  is  necessary,  except  that 
which  is  calculated  to  remove  the  existing  morbid  condition 
of  the  organ.  In  haemorrhage  from  the  bladder  the  cause 
is  different.  Profuse  bleeding  from  this  organ  is  not  infre- 
quent in  malignant  disease,  or  fungous  degeneration  of 
the  mucous  membrane.  The  patient  should  be  placed  on 
his  back,  and  cold  wet  cloths  applied  over  the  hypogastric 
region  and  perinseum.  Ice-water,  or  pounded  ice,  can  be 
thrown  into  the  rectum  at  the  same  time.  Should  the  blad- 
der be  distended  with  clots,  a  large-sized  catheter  must  be 
introduced,  the  clots  broken  up  and  removed ;  warm  water 
injected  through  it  will  soften  the  clots  and  assist  in  their 
discharge.  If  further  measures  be  necessary  to  suppress  the 
bleeding,  the  following  solutions  may  be  injected  into  the 
bladder,  by  means  of  the  catheter : 

3 .  Acidi  gallici     ..*....  3  iij. 

Aquaa fl.  ?  iv.    M. 


38      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 
Or, 

5.   Aluminis 3j- 

AqufB    .        .        .        ,        ,        ,        .        .        .    fl.  I  iv.  If. 

Many  of  the  vegetable  astringents,  as  uva  ursi,  liydras- 
tis,  krameria,  may  be  used  in  a  like  manner. 

In  nretliral  bleeding,  cold  cloths  and  pressure  generally 
answer  all  requirements.  If  there  be  laceration  of  the  erec- 
tile tissue  surrounding  the  urethra,  accompanied  by  danger- 
ous haemorrhage,  a  steel  sound,  or  catheter,  must  be  intro- 
duced in  the  canal,  and  the  penis  bandaged  over  it  firmly. 
This  procedure  is  allowable  in  every  case  which  cannot  be 
controlled  by  other  means.  In  case  injections  into  the  ure- 
thra are  considered  advisable,  solutions  of  iron  may  be  em- 
ployed diluted,  such  as — 

5.   Liquoris  ferri  subsulphatis fl3j. 

AqusB fl|iv.  M. 

Any  thing  stronger  than  this  creates  much  irritation  and 
pain. 

After  amputation  of  the  penis,  or  the  removal  of  tumors, 
the  subsequent  haemorrhage  from  the  erectile  tissue  is  some- 
times BO  profuse  and  uncontrollable  by  ordinary  means  aa 
to  compel  the  surgeon  to  apply  the  actual  cautery.  See  Ap- 
pendix. 

EccHYMOSis  is  an  extravasation  of  blood  in  the  meshes 
of  the  cellular  tissue,  generally  occurring  underneath  the 
integument.  It  is  especially  apt  to  take  place  in  those  parts 
which  are  loosely  attached  to  the  underlying  tissues,  and 
where  there  is  little  subcutaneous  fat.  A  characteristic  ex- 
ample of  this  lesion  is  found  in  the  ordinary  "  black  eye." 


HEMORRHAGE.  39 

Ecchjmosis  follows  blows  and  contusions  of  all  kinds.  Its 
extent  depends  on  the  tissue  bruised,  and  the  amount  and 
kind  of  violence  which  produced  it.  Very  slight  injury  will 
occasion  large  ecchjmosis  in  old  persons,  and  in  those  who 
suffer  from  ansemia  or  other  debilitating  affections.  In  pur- 
pura and  ecorbutis,  blood  is  effused  in  small,  irregular 
patches.     This  is  due  to  deterioration  of  the  circulating 

in 

fluid,  and  not  to  injury.  Tlie  ecchymosed  spot  may  be 
black,  green,  yellow,  or  crimson.  Sometimes  there  is  a  mix- 
ture, the  central  part  being  dark  blue,  while  the  rest  varies 
in  color  from  a  crimson  to  light  green  and  yellow.  The 
coloration  is  due  to  the  red  globules  which  have  escaped 
from  the  ruptured  capillaries,  and  to  the  hematine  of  the 
blood  staining  the  parts.  Where  the  staining  is  caused  by 
hematine  alone,  the  colors  are  light,  and  microscopical  ex- 
amination of  the  extravasated  material  shows  that  no  cor- 
puscles are  present. 

All  bruises  which  are  not  attended  with  grave  destruc- 
tion of  tissue  may  be  treated  with  water-dressings.  The 
injured  part  is  to  be  kept  at  rest  and  covered  with  cold,  wet 
cloths.  If  preferred,  the  bruised  tissue  may  be  bathed  or 
kept  moist  with  the  following  preparation  : 

5.   AmmoniEe  muriat 3j. 

Tinct.  arnicEe fl.  3  j. 

Spts.  vin.  rect. fl.  fij. 

M^^ fl.  fiij.  K 

For  children,  a  further  dilution  is  necessary,  as  thsir  in- 
tegumental  covering  is  much  more  delicate  than  that  of 
adults.  One  or  two  ounces  of  water  added  will  weaken 
it  sufficiently.     This  solution  has  an  admirable  effect  in  pro- 


iO       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

ducing  rapid  absorption  of  the  eflfused  material,  preventing 
inflammation  and  excessive  discoloration.  If  tliere  be  much 
pain,  the  officinal  lead  and  opium  wash  -will  give  relief.  A 
large  extravasation  of  blood  should  be  removed  by  incising 
the  integument. 


CHAPTER  III. 

H^MORBEAGE  FROM  THE  UTERUS. 

Metrorrhagia.  —  Accidental   Hoemorrliage.  —  Placentia  Previa.  —  Post-partum 

Haemorrhage. 

The  periodical  discliarge  of  blood  from  the  uterus, 
whicli  takes  place  every  twenty-eiglit  days,  is  a  physiological 
occurrence,  and  does  not  require  attention  here.  It  rarely 
calls  for  active  treatment,  even  when  in  excess  {menor- 
rhagia). 

Meteoekhagia,  or  bleeding  between  the  monthly  periods, 
may  keep  up  so  constant  a  di'ain  on  the  system  as  to  destroy 
by  exhaustion,  or  predispose  to  fatal  diseases.  Congestion 
of  the  uterus  from  chronic  inflammation,  tumors,  ulcers,  and 
abrasions  of  the  cervix,  are  its  principal  causes. 

The  treatment  of  metrorrhagia  consists  principally  in  the 
application  of  cold  to  the  hypogastrium,  vulva,  and  neck  of  \/ 
the  uterus,  and  the  internal  administration  of  ergot,  gallic 
acid,  acetate  of  lead,  etc.  India-rubber  bags,  filled  with  ice- 
water,  introduced  into  the  vagina  and  pressed  against  the 
cervix  uteri,  may  be  used  with  good  effect.  The  diseases 
causing  the  hgemorrhage  should  subsequently  be  removed, 
and  the  patient's  strength  increased  by  fresh  air,  exercise, 
good  diet,  and  tonics. 

Ante-paethm  H^aioEEHAGE  is  that  variety  which  occurs 
J) 


i2       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

• 

in  the  pregnant  female  before  delivery.  It  is  due  either  to 
partial  separation  of  the  after-birth  from  blows  or  falls  {acci- 
dental hamon'hage),  or  to  placenta  pra3via.  In  tlie  latter 
case,  the  after-birtli  is  attached  around  the  os  internum.  The 
natural  dilatation  of  the  cervix  and  contraction  of  the  uter- 
ine fibres  at  "  full  term  "  cause  its  detachment,  and  bleed- 
ing follows  {unavoidable  hcemoi'i'hage).  Placenta  proevia  is 
attended  with  great  danger,  both  to  mother  and  child.  It 
requires  to  be  diagnosed  from  accidental  haemorrhage.  In 
accidental  hsemorrhage,  the  patient  has  received  a  blow  or 
fall  on  the  abdomen,  the  cervix  is  not  relaxed,  and  the  flow 
of  blood  occm's  between  the  uterine  contractions.  In  una- 
voidable hsemorrhage,  the  bleeding  appears  near  the  time  of 
labor,  and  is  oiot  accompanied  by  a  history  of  injury.  The 
cervix  is  soft  and  patulous,  the  placenta  can  be  felt  over  the 
internal  os,  and  the  haemorrhage  occurs  with,  and  not  be- 
tween, the  uterine  contractions,  as  in  the  former  variety. 

A  patient  suffering  from  accidental  haemorrhage  should 
be  kept  at  rest  in  the  recumbent  posture,  with  the  hips  ele- 
vated. Cold  may  be  applied  to  the  vulva,  and  astringent 
medicines  given.  Some  advise  small  doses  of  ergot.  If  these 
measures  do  not  succeed,  premature  labor  must  be  induced 
and  the  uterus  emptied  (s(3e  Puerperal  Convulsions). 

Placenta  Pk^evia  is  treated  in  one  of  four  ways :  1.  The 
vagina  can  be  tamponed^  and  the  patient  kept  quiet  until 
labor  sets  in.  The  placenta  is  then  removed,  totally,  and 
the  child's  head,  pressing  against  the  open  vessels,  prevents 
further  loss  of  blood.  2.  If  the  haemorrhage  is  profuse,  the 
cervix  may  be  dilated  rapidly,  the  placenta  detached  as  in 
the  first  instance,  and  the  child  extracted  by  means  of  for- 
ceps or  version.    3.  The  after-birth  may  be  partially  detached 


HJilMORRHAGE  FROM   THE   UTERUS.  43 

at  one  side  when  the  os  is  dilated,  and  the  child  delivered 
hy  version.  4.  An  opening  may  be  made  in  the  centre  of 
the  placenta,  the  hand  introduced  through  it,  and  version 
performed. 

Ergot  should  be  freely  administered  while  the  uterus  is 
being  emptied.  This  drug  is  likewise  useful  after  comple- 
tion of  delivery,  in  producing  perfect  tonic  contractions  of 
the  uterine  muscular  fibres,  and  preventing  further  bleed- 
ing. 

PosT-PAETCM  IIuEMORKHAGE  is  ouc  of  the  most  daugerous 
sequelae  of  labor.  Perhaps  in  no  other  haemorrhage  is  there 
such  urgent  necessity  for  presence  of  mind,  or  active  inter- 
ference. There  are  few  varieties  which  so  readily  yield  to 
proper  treatment ;  yet  inferior  remedial  agents,  or  a  few 
moments  of  indecision,  may  place  the  patient  beyond  hope. 
The  stream  of  blood  poured  out  in  the  space  of  half  a  minute 
has  in  some  instances  been  sufficient  to  destroy  life. 

Protracted  labors  which  fatigue  and  lessen  the  vital 
forces  of  the  parturient  woman,  or  labors  which  have  been 
attended  by  operative  procedures,  are  apt  to  be  followed  by 
profuse  bleeding.  Keglect  on  the  part  of  the  physician  or 
of  his  assistant  to  follow  the  uterus  with  the  hand  down 
into  the  pelvis  during  delivery,  and  to  keep  it  contracted 
when  there,  is  one  of  the  most  common  causes.  It  is  not  too 
much  to  say  that,  if  this  precaution  were  observed  with  all 
patients,  a  case  of  immediate  post-partum  haemorrhage 
would  be  exceedingly  rare. 

Women  habitually  subject  to  inertia  uteri  are  especially 
liable,  even  in  ordinary  labors,  to  lose  large  quantities  of 
blood.  These  cases  require  extra  attention.  Injuries  to 
any  part  of  the  internal  genitals,  with  laceration,  and  the 


44      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

hfiemorrliagic  diathesis,  are  also  causes  of  immediate  Leemor- 
rliage. 

"When  portions  of  the  after-birtli  remain  beliind  after 
delivery  of  the  child,  haemorrhage  usually  occurs.  It  does 
not,  however,  show  itself  to  any  great  extent  for  some  days 
subsequent  to  the  labor.  Ketained  placenta  may  be  sus- 
pected in  all  cases  where  a  few  days  elapse  after  delivery  be- 
fore the  bleeding  manifests  itself. 

In  post-partum  hcemorrhage  the  blood  may  be  effused 
into  the  cavity  of  the  uterus,  or,  as  is  generally  the  case,  it 
may  be  poured  out  through  the  vagina. 

The  first  indication  of  haemorrhage  which  may  attract 
the  attention  of  the  attendant,  especially  if  the  woman  be 
covered  or  the  bleeding  internal,  will  be  a  sudden  blanching 
or  pallor  of  the  patient's  countenance,  and  sighing  respira- 
tion. The  pulse  becomes  rapid  and  weak,  or  may  be  com- 
pletely absent.  In  short,  all  the  constitutional  symptoms  of 
profuse  haemorrhage  are  present  {see  page  12).  In  another 
class  of  cases  the  bleeding  is  slower,  the  constitutional 
effects  less  suddenly  manifested ;  but  in  all  they  appear  to  a 
greater  or  less  degree. 

Treatment. — The  preventive  treatment  consists  in  press- 
ing the  uterus  firmly  down  into  the  pelvic  cavity  as  it  is 
being  emptied  of  its  contents,  and  to  keep  the  hand  over  it 
until  it  is  felt  to  be  contracted  like  a  hard  ball  in  the  pelvic 
cavity.  Some  recommend  the  administration  of  ergot  before 
and  after  the  delivery  of  the  placenta,  as  a  preventive  meas- 
ure. I  administered  it  quite  frequently  for  that  purpose 
in  the  Lying-in  Department  of  Bellevue  Hospital,  and  with 
good  results. 

For  suppressing  the  hsemorrhage,  several  methods  are 


HyEMORRHAGE  FROM  THE  UTERUS.  45 

advised.  When  the  bleeding  is  very  profuse,  the  surest 
method  is  to  introduce  one  hand  into  tlie  uterus,  turning  out 
all  the  clots,  while  at  the  same  time  the  other  hand  grasps 
the  organ  on  the  outside,  and  firm  pressure  is  made  until  the 
hand  is  forced  out  by  the  uterine  contractions.  A  piece  of 
ice  may  be  carried  into  the  cavity,  and  applied  to  the  in- 
ternal surface  of  the  uterus,  if  necessary.  The  physician 
must  be  governed  by  circumstances  in  its  use.  There  are 
cases  which  cannot  be  controlled  without  it.  Some  object 
to  the  introduction  of  the  hand  into  the  uterus,  because  they 
think  it  apt  to  injure  the  walls,  produce  endo-metritis  and 
other  disorders.  This  danger  is  probably  somewhat  exag- 
gerated. The  pressure  of  the  closed  hand  for  a  few  moments 
on  the  inner  surface  of  the  contracting  uterus  will  certainly 
not  produce  greater  harm  than  the  pressure  on  the  irregular 
prominences  of  the  child's  body  during  a  labor  of  several 
hours'  duration.  The  only  danger  there  can  be  is  from 
septic  material  finding  its  way  inside  on  the  hands  of  the 
physician,  and  this,  to  say  the  least,  is  very  improbable. 

Another  method  is  to  grasp  the  uterus  firmly  and  knead 
it  with  the  fingers  until  contractions  ensue.  Lumps  of  ice 
may  be  rubbed  over  the  abdomen  at  the  same  time,  or  ice- 
water  poured  on  the  abdominal  walls. 

Prof.  Thompson,  of  this  city,  claims  to  have  obtained 
good  results  from  the  application  of  ether-spray  over  the 
hypogastrium.  Injections  of  astringent  medicines  into  the 
cavity  of  the  uterus  have  been  employed,  but  are  considered 
extremely  dangerous  by  most  obstetricians.  In  conjunction 
with  all  the  varieties  of  local  treatment  mentioned,  ergot 
should  be  administered  in  large  doses  at  repeated  intervals. 
Its  use  is   always   indicated.     The  subsequent  treatment 


iQ  EMERGENCIES,  AND  HOW  TO  TREAT  TBEM. 

depends  on  the  amount  of  blood  lost.  If  there  be  much 
exhaustion,  the  usual  stimulants,  together  with  small  doses 
of  opium,  may  be  given ;  and,  as  a  last  resort  to  save  from  im- 
pending death,  the  operation  of  transfusion,  referred  to  in  a 
former  chapter,  may  be  employed.  Injections  of  hot  water 
have  also  been  employed  with  great  advantage. 


CHAPTER  IV. 

WOUNDS  OF  IMPORTANT  ORGANS. 

Wounds  of  the  Throat,  Lungs,  Pericardium,  Heart,  Ahdomen,  Intestines,  Blad- 
der, Perinseum,  Joints,  Arteries,  Veins. — Perineal  Section. — Paracentesis, 
Thoracis. — Gunshot  Wounds,  etc. 

Wounds  of  the  tliroat  vary  in  extent,  from  simple  in- 
cision of  the  integument  to  complete  severance  of  the  larynx, 
trachea,  and  oesophagus.  They  are  inflicted  with  razors  or 
other  sharp  cutting  instruments,  and  are  usually  the  result 
of  attempted  self-murder.  The  upper  part  of  the  throat 
seems  to  be  the  point  of  selection  in  these  cases :  rarely 
is  the  cut  made  at  the  lower  portion.  The  carotid  artery 
and  jugular  vein  are  thus  saved,  and  a  better  chance  of  re- 
covery given  to  the  patient. 

In  the  majority  of  wounds  of  the  throat  an  opening  is 
made  into  the  air-passages.  The  most  common  seat  of  these 
wounds  is  between  the  thyroid  cartilage  and  hyoid  bone, 
and  over  the  larynx.  In  the  former  the' thyro-hyoid  mem- 
brane is  cut  through  ;  the  epiglottis  may  be  cut  off,  or  in- 
jured so  as  to  seriously  affect  the  power  of  swallowing.  The 
food  may  pass  without  hinderance  into  the  larynx  and  out 
of  the  external  opening,  as  the  epiglottis  is  not  in  place 
to  prevent  it,  or  is  in  a  semi-paralytic  condition  from  the 
injury,  and  fails  to  appreciate,  or  prevent  the  passage  of  the 
food  down  the  wrong  canal.     The  appearance  of  food  in  the 


48  EMERGENCIES,   AND   HOW   TO   TREAT   TnEil. 

wound  is  therefore  not  a  positive  indication  of  injury  to  the 
oisophagns. 

^Vounds  inflicted  on  the  side  of  the  neck  may  cut  the 
pneuraogastric  or  phrenic  nerves.  In  such  cases  there  is 
interference  with  tlie  respiratory  movements,  and  subse- 
quent congestion  of  tlie  lungs,  which  may  ultimately  destroy 
life,  independent  of  any  other  complications.  Wounds  of 
the  back  of  the  neck,  unless  implicating  the  spinal  cord,  are 
not  fatal.  Some  authorities  say  that  they  are  followed  by 
paralysis  of  the  lower  limbs  and  loss  of  sexual  power ;  this 
is  doubtful. 

Wounds  inflicted  between  the  lower  jaw  and  hyoid  bone 
are  the  least  dangerous  of  anterior  wounds,  although  they 
are  sometimes  attended  with  great  hcemorrhage  and  with 
difliculty  in  swallowing  (dysphagia). 

The  danger  and  causes  of  death  in  wounds  of  the  throat 
are :  1.  Hcemorrhage ;  2.  Asphyxia.  3.  Inflammation  of 
the  air-passages  and  lungs,  as  laryngitis,  bronchitis,  and 
pneumonia.     4.  Nervous  depression  and  starvation. 

The  principal  danger  is  from  excessive  bleeding.  Bleed- 
ing may  be  profuse  even  in  superficial  wounds.  The  blood 
from  the  numerous  plexuses  of  veins  in  front  of  the  neck 
and  around  the  thyroid  gland  may  flow  in  sufficient  quan- 
tity to  destroy  life.  When  the  large  vessels,  such  as  the 
carotid  arteries  or  jugular  veins,  are  cut,  death  occurs  in  a 
few  moments. 

Secondary  haemorrhage  not  unfrequently  takes  place 
from  sloughing  of  the  walls  of  the  vessels,  between  the 
tenth  and  the  twentieth  day. 

Asphyxia  may  arise  from  infiltration  of  serum  into  the 
mucous  membrane  of  the  larynx  at  its  upper  part  {oedema 


WOUNDS  OF  IMPORTANT  ORGANS.  49 

glottidis),  or  from  blood  flowing  down  into  tlic  fiir-passagcs. 
Internal  liEemorrliage  may  go  on  slowly  for  some  time  with- 
out attracting  special  attention,  the  shock  of  the  injury 
and  deficient  aeration  of  the  blood  benumbing  the  sensibility 
of  the  mucous  membrane. 

Laryngitis  may  occur  from  extension  of  inflammation 
from  surrounding  parts,  or  directly  from  a  wound  of  the 
larynx.  The  most  dangerous  inflammations  are  bronchitis 
and  pneumonia.  These  complications  arise  principally  from 
the  inhalation  of  cold  air  through  the  opening  in  the  throat. 
In  ordinary  breathing,  the  air  is  heated  by  passing  through 
the  nose,  and  thus  loses  its  irritating  qualities. 

In  all  suicidal  attempts  upon  life,  there  is  extreme  men- 
tal depression,  which  tends  to  prevent  recovery. 

Treatment. — As  the  great  danger  arises  from  loss  of 
blood,  the  first  efforts  are  directed  to  suppress  the  flow. 
This  is  accomplished  either  by  means  of  jgressure^  or  with 
the  ligature.  If  the  bleeding  vessel  cannot  be  reached  in 
the  wound,  sufficient  pressure  may  be  made  to  stop  the  hsera- 
orrhage,  while  the  upper  or  lower  portions  of  the  wound 
are  enlarged  and  the  vessel  searched  for.  Should  it  not  be 
found,  and  the  haemorrhage  be  still  threatening,  the  carotid 
arteries  must  be  tied.  If  the  wound  does  not  implicate  the 
air-passages,  the  edges  may  be  drawn  together  with  strips 
of  adhesive  plaster.  In  doing  this,  care  should  be  taken  to 
leave  an  opening  for  the  discharges  from  the  wound.  The 
cellular  tissue  of  the  neck  is  very  loose,  and,  unless  this  be 
done,  pus  and  other  inflammatory  products  will  burrow  at 
the  base  of  the  neck,  between  the  muscles  and  vessels,  and 
produce  serious  trouble.  The  same  rule  holds  good  when 
the  wound  extends  into  the    air-passages.      No   attempt 


50       EMERGENCIES,  AND  EOW  TO  TREAT  TEEM. 

should  be  made  to  close  the  aperture  for  several  hours,  or 
until  all  danger  from  haemorrhage  has  passed  away.  Even 
then  the  central  portion  of  the  wound  should  remain  un- 
closed for  the  exit  of  the  subsequent  discharges.  In  closing 
the  wound  and  preventing  gaping,  the  head  should  be  flexed 
on  the  neck,  and  retained  there  by  means  of  bandages 
passed  over  the  head  and  under  the  arms.  Cloths  wet  with 
cold  water  may  then  be  applied  to  lessen  inflammation.  If 
there  is  venous  oozing  in  the  canal,  a  large  tube  may  be  in- 
troduced, and  pressure  made  by  plugging  around  it  {Ericc- 

S07l). 

"When  the  oesophagus  is  wounded,  the  patient  can  be  fed 
through  the  opening  by  means  of  a  flexible  catheter,  or  the 
tube  of  an  ordinary  stomach-pump.  I  have  found  the  latter 
to  be  much  better  for  the  purpose  than  the  catheter,  as  a 
larger  quantity  of  food  can  be  introduced  in  a  given  space 
of  time,  and  the  wound  therefore  sooner  relieved  from  the 
presence  of  an  irritating  substance. 

Patients  should  always  be  removed  to  a  very  warm  room, 
with  a  temperature  of  from  80  to  85°  Fahr.  Stimulants, 
and  nourishing  diet,  in  the  shape  of  beef-tea  or  chicken- 
broth,  should  be  freely  administered. 

"Wounds  of  the  Thorax,  Lungs,  etc. — Non-penetrating 
wounds  of  the  thorax  are  treated  like  simple  wounds  in  other 
parts  of  the  body.     They  do  not  require  consideration  here. 

Penetrating  wounds  may  involve  the  internal  mammary 
and  intercostal  arteries,  the  pleura,  lungs,  heart,  and  great 
vessels,  either  alone  or  collectively.  When  the  internal 
mammary  artery  is  cut,  the  blood  flows  slowly  into  the  an- 
terior mediastinum,  or  into  one  or  the  other  pleural  cavities. 
It  is  diagnosed  by  the  location  of  the  wound  and  the  grad- 


WOUNDS  OF  IMPORTANT  ORGANS.  51 

ual  development  of  syncope  consequent  upon  the  loss  of 
blood. 

The  protection  afforded  to  the  intercostal  vessels,  by  the 
long  groove  in  which  they  run,  happily  prevents  them  from 
being  wounded,  except  in  very  rare  instances.  In  wounds 
of  these  vessels,  the  h£emorrhage  may  take  place  in  the  cavi- 
ties of  the  pleura,  underneath  the  muscles  and  fascia  of  the 
chest,  or  escape  internally.  The  immediate  danger  to  life 
is  not  very  great,  but  the  utmost  difficulty  in  suppressing 
the  haemorrhage  is  commonly  experienced. 

Penetrating  wounds  of  the  chest,  without  injury  to  the 
lungs,  are  exceptional.  Injury  to  the  lungs  may  be  ex- 
cluded, if  there  is  no  expectoration  of  blood,  or  haemorrhage 
from  the  wound.  If  the  hole  is  large,  sufficient  air  may 
pass  into  the  cavity  of  the  pleura  to  compress  the  lung  and 
completely  destroy  its  action.  In  such  a  case,  death  may 
ensue. 

The  most  dangerous  wounds  of  the  lung  are  produced 
by  bullets.  Foreign  bodies  in  the  delicate  structures  of  the 
lung  cause  great  irritation,  and  more  inflammation  than 
simple  laceration  would.  They  are  not,  however,  necessarily 
fatal.  Many  instances  are  on  record  of  foreign  bodies  re- 
maining embedded  in  the  lung-substance  for  years,  without 
interfering  specially  with  respiration.  In  the  summer  of  1868, 
I  made  a  post-morte')n  examination  on  the  body  of  Major 
D ,  an  old  Mexican  veteran  who  had  received  a  gunshot- 
wound  twenty  years  before.  In  the  upper  portion  of  the 
left  lung  was  embedded  a  large,  old-fashioned  musket-bullet, 
completely  encysted.  The  lung  was  about  one-quarter  its 
original  size,  and  was  carnified  around  the  projectile.  The 
major  had  enjoyed  comparatively  good  health,  notwithstand- 


52  E5IERGENCIES,  AND  HOW  TO  TREAT  THEM. 

ing  its  preseiicic.  lie,  strangely  enough,  supposed  that  the 
bullet  was  in  tlie  lung  of  the  opposite  side,  and  his  friends 
were  of  the  same  opinion. 

The  signs  of  a  wound  of  the  lung  are  plain  and  well 
marked.  There  is  great  difficulty  in  breathing  (dt/sjjnosa), 
expectoration  of  blood  {hcemoptysis\  and  of  red,  frothy 
mucus  from  the  air-passages,  and  emphysema.  There 
may  or  may  not  be  haemorrhage  from  the  external  open- 
ing. On  auscultation,  small  moist  rales  may  be  heard  near 
the  seat  of  injury.  The  patient's  face  is  pallid  and  anxious, 
and  the  pulse  small  and  rapid.  In  some  cases  the  bleeding 
goes  on  inside  the  chest,  until  the  lung  is  compressed  by  it, 
and  signs  of  syncope  show  themselves.  Internal  haemor- 
rhage may  be  diagnosed  by  the  increased  paleness  of  the 
countenance,  flickering  pulse,  vertigo,  and  dimness  of  vision, 
increased  dulness  over  the  affected  side,  absence  of  the  res- 
piratory murmur.  If  the  blood  be  poured  out  to  any  ex- 
tent in  the  parenchyma  of  the  lung,  there  will  be  dulness  on 
percussion  near  the  wound,  and  bronchial  breathing. 

The  passage  of  air  into  the  cellular  tissue  {emphysema) 
is  a  common  accompaniment  of  wounds  of  the  lung.  It 
may  occur  when  a  part  of  the  lung-tissue  is  ruptured  by 
pressure  on  the  chest-walls,  or  penetrated  by  the  broken  end 
of  a  rib,  independent  of  any  external  wound.  "When  it 
proceeds  from  rupture  of  the  vesicles  alone,  and  extends  to 
the  surface,  its  usual  course  is  through  the  cellular  tissue 
of  the  posterior  mediastinum  up  to  the  neck,  whence  it 
travels  to  other  parts  of  the  body.  A  case  of  this  kind 
came  under  my  care  in  Bellevue  Hospital,  in  a  patient 
whose  chest  had  been  severely  injured  by  a  derrick.  The 
ribs  were  not,  however,  broken.     In  a  few  hours  after  ad- 


WOUNDS  OF  IMPORTANT  ORGANS.  53 

mission  to  tlie  ward,  emphysema  manifested  itself,  and 
Bpread  slowly  over  tlie  neck  and  face,  and  finally  involved 
the  thorax  and  abdomen.  The  face,  arms,  and  trunk,  became 
distended  to  an  extreme  degree.  He  suffered  greatly  from 
pain  and  difficult  respiration.  There  was  some  expectora- 
tion of  a  reddish-colored,  tenacious  mucus,  circumscribed 
bronchial  breathing  over  the  left  lung,  near  the  apex,  a  hot 
skin  and  rapid  pulse,  with  other  indications  of  pneumonic 
inflammation.  It  was  regarded  as  a  hopeless  case.  In  ten 
days  from  the  time  of  admission,  the  emphysema  diminished 
rapidly,  and,  at  the  end  of  three  weeks,  no  trace  of  it  was 
present.     The  patient  was  discharged  cured. 

In  wounds  which  open  externally,  the  air  is  drawn  in 
with  each  inspiration,  and  forced  out  during  expiration, 
some  of  it  passing  into  the  cellular  tissue.  It  may  remain 
localized  near  the  wound,  or  it  may  extend  gradually  to 
other  parts.  Emphysema  is  always  recognized  by  the 
elasticity  of  the  swelling,  and  by  the  peculiar  crack- 
ling, crepitant  sensation,  communicated  to  the  fingers  on 
pressure. 

The  air,  instead  of  passing  out  into  the  cellular  tissue, 
may  accumulate  in  the  pleural  cavity,  giving  rise  to  jmeumo- 
thorax.  In  certain  cases  of  haemorrhage,  this  has  a  salutary 
rather  than  an  injurious  effect,  as  the  compression  of  the 
lungs  will  stop  the  flow  of  blood. 

Pneumocele,  or  hernia  of  the  lung,  may  take  place  be- 
fore the  external  wound  heals,  or  after  it  is  entirely  closed. 
"When  protruded  through  the  wound,  it  may  be  pushed 
partly  back,  and  the  aperture  closed  by  a  compress.  Some 
cases  of  pneumocele  have  been  treated  by  cutting,  and  by 
strangulating  the  extruded  portion.     If  the  hernia  be  a 


54  EMERGENCIES,   AND   HOW  TO   TREAT   THEM. 

remote  result  of  the  wound,  and  covered  by  tlie  integument, 
all  that  is  necessary  is  to  protect  it  by  a  hollow  pad. 

T/'eatment. — When  the  intercostal  arteries  are  wound- 
ed, they  may  be  either  compressed  or  ligated.  Ligation  ia 
almost  impossible.  The  best  method  is  to  fasten  a  piece  of 
sponge  to  a  ligature  and  force  it  through  the  wound  into  the 
cavity  of  the  chest,  and  then  draw  it  partially  outward  so 
as  to  make  it  press  directly  upon  the  arteries  {Poland). 
Digital  compression,  kept  up  by  relays  of  assistants,  has  in 
some  cases  been  effectual.  Some  recommend  passing  a  silk 
or  wire  ligature  around  the  rib,  drawing  tightly,  and  thus 
closing  the  wounded  vessel.   See  Appendix. 

Others  close  the  external  wound,  and  allow  the  blood  to 
escape  into  the  cavity  of  the  chest.  A  large  quantity  of 
blood  may  be  lost  in  this  way,  but  not  enough  to  destroy  life. 

"Wounds  of  the  internal  mammary  arteries  are  more  diffi- 
cult to  reach  than  the  preceding.  Pressure  may  be  tried,  in 
the  manner  described  above.  If  it  do  not  succeed,  ligation 
may  be  resorted  to.  This  operation  is  usually  performed  at 
some  point  above  the  fourth  interspace ;  below  this  point, 
the  operation  cannot  succeed. 

The  method  of  ligating  the  artery  is  described  by  Dr. 
Poland  *  as  follows :  "  An  incision  is  made  two  inches  in 
length  along  the  side  of  the  sternum,  and  in  an  oblique 
direction,  from  above  downward,  and  from  without  inward, 
forming  with  the  axis  of  the  body  an  angle  of  forty-five 
degrees :  the  centre  of  the  incision  to  be  three  or  four  lines 
from  the  border  of  the  sternum. 

"  Having  divided  the  skin,  cellular  tissue,  and  origin  of 
the  pectoralis  major  muscle,  the  intercostal  space  is  brought 

*  Holmes's  Surgery,  article  Wounds. 


WOUNDS  or  IMPORTANT  ORGANS.  55 

into  view ;  the  intercostal  muscle  is  now  carefully  divided 
upon  a  director,  and  the  edge  drawn  apart  by  retractors, 
and  the  arteries  exposed." 

In  Wounds  of  the  Lung  an  attempt  must  be  made  to  con- 
trol the  haemorrhage  by  internal  medication.  Small  doses 
of  acetate  of  lead,  sulphuric  acid,  alum,  or  other  astringents, 
may  be  given.  Ice  applied  externally  is  always  of  service. 
Should  the  blood  accumulate  in  the  interior,  it  must  be 
removed.  If  it  does  not  flow  out  by  changing  the  position 
of  tlie  patient,  a  cupping-glass  may  be  placed  over  the 
aperture,  and  the  fluid  started  in  this  way.  Of  course,  this 
procedure  should  not  be  instituted  while  any  danger  of 
further  haemorrhage  remains.  Some  prefer  enlarging  the 
external  wound,  while  others  allow  it  to  heal,  and  after- 
ward -perform  paracentesis  thoracis. 

This  operation  is  usually  made  posteriorly  near  the  angle 
of  the  scapula,  between  the  seventh  and  eighth  ribs.  The 
best  instrument  to  employ  is  a  small  trochar  and  canula. 
"When  the  point  of  opening  is  selected,  the  integument  is 
incised  with  a  scalpel,  and  the  trochar  introduced.  As  the 
stylet  is  withdrawn,  the  patient  should  be  turned  over  on 
the  affected  side,  and  firm  pressure  made  on  the  thoracic 
walls.  In  this  way  there  is  little  danger  of  air  entering  the 
cavity.  Dr.  Bowditch,  of  Boston,  uses  a  suction  apparatus 
to  prevent  air  from  passing  in,  and  to  assist  in  evacuating 
the  liquid.     Dieulafoy's  aspirator  answers  all  purposes. 

When  the  hsemorrhage  has  ceased,  the  external  wound  is 
thoroughly  closed,  and  the  lips  held  together  by  adhesive 
plaster.  Simple  water-dressings,  dipped  in  a  solution  of  car- 
bolic acid,  are  then  applied  over  the  part  until  it  is  healed. 

If  pneumo-thorax  exist  of  sufficient  extent  to  compress 


56  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

the  lung,  the  enclosed  air  may  be  extracted  by  Buetion, 
through  the  external  wound,  or  by  making  a  new  puncture 
in  the  chest-walls. 

The  subsequent  inflammation  of  the  lung-tissue  is  treated 
by  counter-irritation  over  tlie  chest,  diaphoretics,  anodynes, 
etc. 

"WouxDS  OF  THE  Peeic^vrdium. — A  punctured  wound  in 
the  prcccordial  region,  which  does  not  implicate  the  heart 
or  great  vessels,  is  of  rare  occurrence.  Such  a  wound  may 
prove  fatal  from  the  entrance  of  blood  or  air  into  the  peri- 
cardial sac,  pressing  upon  the  heart  so  as  to  paralyze  its 
movements.  The  inflammation  of  the  pericardium  which 
follows  a  wound  of  this  kind  may  also  destroy  life. 

This  wound  is  recognized  by  the  ordinary  signs  of  peri- 
carditis. Upon  auscultation  there  is  heard  a  dry,  rubbing 
friction-sound  accompanying  the  cardiac  impulses.  This  is 
succeeded  by  an  augmentation  of  the  area  of  prsecordial 
dulness  from  effusion,  and  by  diminished  intensity  of  the 
heart-sounds,  and  feeble  pulsations.  The  constitutional 
effects  are  shown  by  a  rapid,  irritable  pulse,  hot  skin,  and 
anxious  face. 

When  the  hemorrhage  has  been  controlled,  the  wound 
is  closed  in  the  ordinary  way,  and  opium  is  administered 
in  full  doses.  Blisters,  dry  or  wet  cups  over  the  proecordia, 
are  effective  agents  in  subduing  the  inflammation. 

'Wo^^^)S  of  the  Heart  may  be  instantaneously  fatal,  or 
life  may  be  prolonged  for  several  days.  The  case  of  a  noted 
pugilist  of  this  city,  named  Poole,  will  be  remembered.  He 
received  a  bullet-wound  in  the  heart,  and  walked  home 
afterward.  Death  did  not  occur  for  hours  after  the  injury 
was  inflicted. 


WOUNDS  OF  IMPORTANT  ORGANS.  57 

Small  punctured  wounds  of  the  heart  have  been  known 
to  terminate  in  recovery. 

A  wound  of  the  auricles  is  more  rapidlj  fatal  than  a 
wound  of  the  ventricles.  The  walls  of  the  former  are  thin- 
ner, and  the  fibres  more  uniformly  arranged,  and  their  con- 
tractions less  likely  to  prevent  haemorrhage.  The  muscular 
walls  of  the  ventricles  are  thick,  and  the  fibres  interlaced, 
and,  if  the  wound  be  small,  profuse  bleeding  cannot  occur. 

The  signs  of  wounds  of  the  heart  are  those  of  shock  and 
loss  of  blood.  The  patient  becomes  rapidly  insensible,  and 
the  pulse  ceases.  There  is  extreme  pallor.  The  extremities 
are  cold  and  sometimes  clammy.  When  the  immediate 
danger  has  passed,  signs  of  pericarditis  appear.  If  life  be 
prolonged  sufficiently  to  give  chance  for  treatment,  the  pa- 
tient is  to  be  kept  perfectly  quiet,  the  wound  closed,  and 
covered  with  cold-water  dressings.  Opium  is  given  inter- 
nally, and,  when  inflammation  appears,  remedies  are  em- 
ployed as  in  the  preceding  case. 

"Wounds  of  the  Abdomen  oe  ns  Contents. — Penetrat- 
ing wounds  of  the  abdomen  are  generally  either  punctured 
or  incised.  Lacerated  wounds  are  not  frequent.  If  the 
bleeding  is  in  any  way  profuse,  the  vessels  should  be  tied. 
If  the  wound  is  small,  so  as  to  make  it  impossible  to  reach 
the  vessel,  the  opening  must  be  enlarged  to  make  it  acces- 
sible. When  there  is  simply  an  oozing  from  the  wound,  in- 
terference is  not  necessary.  It  is  better  for  the  blood  to 
escape  outside  than  into  the  peritoneal  cavity.  The  great 
danger  in  these  cases,  as  in  all  wounds  of  the  abdomen  or 
its  contents,  is  peritonitis.  This  dreaded  complication  is 
made  known  by  the  occurrence  of  a  sharp  pain  near  the 
wound,  which  soon  extends  over  the  whole  abdomen.   There 


5S  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

ai'e  also  tympanitis,  constipation,  and  vomiting.  The  pulse  is 
hard,  tense,  and  wiry.  The  skin  is  dry  and  the  temperature 
increased.  "When  the  intestines  are  wounded,  there  is  still 
greater  liability  to  peritonitis.  If  the  opening  is  large,  there 
is  always  an  escape  of  fecal  matter  into  the  peritoneal  cav- 
ity. This  ii-ritating  material  is  certain  to  excite  peritonitis, 
even  when  in  minute  quantities,  A  small  wound  of  the 
intestines  may  be  closed  by  eversion  of  the  mucous  mem 
brane. 

Treatment. — If  the  intestines  protrude  externally,  and 
cannot  easily  be  returned  through  the  wound,  the  opening 
should  be  enlarged.  The  intestine  should  be  cleansed  thor- 
oughly in  tepid  water  before  it  is  returned.  If  the  intestinal 
wound  is  more  than  three  or  four  lines  in  length,  its  edges 
should  be  drawn  together  by  means  of  sutures.  An  oj)ening, 
of  such  a  size  as  to  be  completely  closed  by  the  everted 
lining  membrane,  may  be  let  alone.  Ericpeon  recommends 
passing  a  ligature  around  this  variety,  in  order  to  make  the 
escape  of  fecal  matter  an  impossibility. 

In  dealing  with  wounds  of  the  abdominal  wall,  there  is 
some  discrepancy  of  opinion.  Some  believe  that  the  sutures 
should  merely  include  the  skin,  and  not  the  deeper  structure 
below.  It  is  reasonable  to  suppose  that,  in  closing  the  wound 
in  this  way,  a  separation  to  a  greater  or  less  extent  would 
take  place  in  that  portion  below  the  integument.  Inflam- 
matory products  must  fill  up  the  gap,  and  there  is  nothing 
to  prevent  their  getting  into  the  peritoneal  cavity  and  giving 
rise  to  peritonitis.  Unless  there  are  special  indications  to 
prevent  it,  it  is  better  to  pass  the  needle  down  to  the  peri- 
tonceum,  and  bring  all  parts  of  the  wound  in  complete  ap- 
position.  If  there  is  much  suppuration  following  the  wound, 


WOUNDS  OF  IMPORTANT  ORGANS.  59 

it  should  be  opened,  kept  clean  with  carholic-acid  wash,  and 
free  escape  of  pus  allowed. 

Opium  is  given  internally  to  control  the  inflammation 
and  allay  pain.  The  patient  should  be  brought  under  its 
influence  until  his  respirations  are  down  to  14,  and  his 
skin  perspiring.  Light  poppy  fomentations  are  also  of 
much  benefit. 

Contusion  of  the  abdominal  walls  may  lacerate  the  in- 
tegument or  muscles,  and  tlie  viscera  within.  The  internal 
organs  alone  may  be  injured,  without  any  perceptible  lesion 
of  the  walls.  Severe  contusions  are  scarcely  ever  recovered 
from.  As  a  good  example  of  the  manner  in  which  these 
wounds  are  received,  and  their  mode  of  termination,  the  fol- 
lowing case  may  be  of  interest : 

James  D.,  aged  twenty-seven ;  occupation,  laborer ;  was 
admitted  to  Ward  11,  Bellevue  Hospital,  sufiering  from 
a  severe  contusion  of  the  abdomen.  He  had  been  riding 
on  the  rear  platform  of  a  Third-Avenue  car,  which  was 
driven  at  considerable  speed.  The  car  suddenly  came  to  a 
halt  at  the  corner  of  a  street.  A  hack  running  behind, 
on  the  track,  failed  to  stop  at  the  same  time,  and,  its  im- 
pulse being  continued,  the  pole  of  the  vehicle  struck  D. 
in  the  abdomen,  near  the  umbilicus,  pressing  him  with  great 
violence  against  the  back  of  the  car.  On  admission,  the 
patient  was  suffering  somewhat  from  shock,  and  the  abdo- 
men was  exceedingly  tender  at  the  point  of  injury. 

The  day  following,  inflammation  set  in.  The  abdomen 
enlarged,  and  was  so  tender  that  the  weight  of  the  bed- 
clothes could  scarcely  be  borne.  Peritonitis,  in  all  its 
phases,  was  well  marked.  Death  took  place  on  the  fourth 
day.    A  post-mortem  examination  showed  that  a  portion  of 


60       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

the  small  intestine  was  niiicli  bruised,  but  its  walls  bad  not 
been  torn  through.  Pus  and  lymph  in  considerable  quanti- 
ties covered  the  intestines,  gluing  them  together  in  several 
places. 

"When  the  liver  and  kidneys  are  ruptured,  there  is 
usually  more  collapse  than  in  injury  of  the  intestines. 
The  patient  rarely  lives  long  enough  to  develop  peri- 
tonitis. 

A  puncture  or  rupture  of  the  bladder  is  succeeded  by 
peritoneal  inflammation.  The  urine  may  pass  into  the  ab- 
dominal cavity  or  into  the  abdominal  walls.  In  the  latter 
case,  the  wound  is  below  the  part  where  the  peritonaeum  is 
reflected  over  the  organ.  If  the  laceration  is  at  the  base, 
the  point  of  a  catheter  may  pass  through  and  be  felt  in  the 
rectum.  The  escape  of  urine  into  the  peritoneal  cavity  is 
attended  with  a  sharp  pain,  which  rapidly  increases  till  the 
peritonaeum,  through  its  extent,  is  involved  in  inflammation. 
In  the  cellular  tissue  of  the  pelvis  or  groin,  it  excites  diffuse 
suppurative  inflammation. 

Treatment. — ^When  the  urine  accumulates  in  the  cellular 
tissue,  free  incisions  are  made  to  give  it  exit.  It  is  prevent- 
ed from  accumulating  in  the  bladder  by  allowing  it  to  run 
out  through  a  catheter  introduced  for  that  purpose.  Opium, 
in  full  doses,  is  beneficial. 

"WoiTNDS  OF  THE  Perin-eum. — Lacerated  wounds  of  this 
part  occur  frequently  in  women  during  labor.  The  child's 
head,  as  it  is  forced  down  by  the  uterine  contractions,  is 
pressed  against  the  distended  perinoeum,  and,  if  it  is  at  all 
resistant,  rupture  takes  place.  As  soon  as  labor  has  termi- 
nated, the  edges  of  the  wound  should  be  brought  together 
by  sutures. 


WOUNDS  OF  IMPORTANT  ORGANS.  61 

In  the  male,  these  wounds  arc  liable  to  injure  the  ure- 
thral canal,  and  operative  measures  are  necessary  to  relieve 
the  resulting  retention  of  urine  and  effect  a  cure.  Perineal 
section  is  usually  performed. 

When  the  patient  has  been  fully  anaesthetized,  a  staff  or 
steel  sound  is  passed  down  to  the  laceration  and  through  it, 
if  possible,  and  the  tissue  of  the  perinseum  divided  in  the 
median  line  down  to  that  point.  The  external  incision  ex- 
tends from  the  termination  of  the  scrotum  to  within  half  an 
inch  of  the  anus.  The  knife  is  then  carried  on  in  the  di- 
rection of  the  urethra  until  the  injured  portion  has  been 
passed.  A  catheter  is  then  introduced  into  the  bladder  and 
retained  for  forty-eight  hours,  to  keep  the  canal  open  and 
allow  free  passage  of  the  urine.  A  steel  sound  is  afterward 
occasionally  introduced  to  prevent  narrowing  of  the  urethra. 
As  this  operation  is  performed  in  its  most  difficult  point 
without  a  guide,  the  anatomical  relations  must  be  borne  in 
mind.  The  urethra  passes  through  the  triangular  ligament 
from  three-quarters  to  an  inch  below  the  pelvis.  The  open- 
ing in  this  ligament,  when  appreciated  by  the  touch,  will 
be  sufficient  to  keep  the  operator  from  cutting  in  wrong  di- 
rections. "When  a  deep,  perineal  wound  bleeds  profusely, 
and  the  vessels  cannot  be  tied,  a  small  Barnes  dilator  may 
be  pushed  into  the  opening  and  filled  with  ice-water.  Dr. 
Synott,  one  of  the  Bellevue  house-surgeons,  first  employed 
this  method.  It  has  proved  successful.  Another  plan  is  to 
place  a  piece  of  oil-silk,  or  other  suitable  material,  around  a 
lead-pencil,  pass  it  into  the  wound,  and  pack  tightly  between 
the  oil-silk  and  pencil  a  quantity  of  lint.  Ice-bags  may 
afterward  be  applied  to  the  wound  to  prevent  inflammation. 
If  the  blood  from  the  urethra  flows  out  at  the  meatus  uri- 


02  EilERGEXCIES,  AND   HOW  TO   TREAT  THEM. 

narius,.  a  sound  is  passed  down  the  canal  and  the  penis 
compressed  against  it  with  a  bandage. 

Fractiu'es  of  the  pelvis  are  sometimes  associated  with 
hicerated  wounds  of  the  perina?uni.  Tlie  following  case  is  a 
good  illustration . 

Patrick  C,  aged  forty ;  occupation,  laborer;  was  injured 
while  exposing  himself  in  an  unnecessary  manner  over  the 
end  of  a  dock.  A  ferry-boat,  coming  into  the  slip  at  the 
time,  crushed  him  against  the  timbers  of  the  M'harf.  He 
was  brought  to  Ward  16,  Bellevue  Hospital,  a  few  hours 
afterward.  An  external  examination  failed  to  detect  a  frac- 
ture. A  catheter  was  introduced,  but  met  with  an  obstruc- 
tion about  the  termination  of  the  membranous  portion  of 
the  urethra.  As  there  was  considerable  urine  in  the  blad- 
der, it  was  decided  to  perform  perineal  section  without  de- 
lay. Ether  was  administered  to  the  patient.  An  incision 
was  then  made  through  the  tissues  in  the  median  line,  com- 
mencing near  the  base  of  the  scrotum  and  carried  wathin  half 
an  inch  of  the  anus.  When  I  reached  the  membranous  por- 
tion of  the  urethra,  I  found  fragments  of  bone  pressing  upon, 
and  completely  obliterating,  the  canal.  The  ramus  of  the 
pelvis,  and  a  portion  of  the  body  of  that  bone,  were  broken 
in  several  fragments.  The  deljris  of  soft  tissue  and  bone 
blocked  up  the  rest  of  the  urethra  to  the  bladder.  An  open- 
ing was,  however,  made  into  the  organ,  and  the  obstruction 
removed.  The  amount  of  fracture  and  destruction  of  tissue 
rendered  his  case  hopeless.  Inflammation  set  in  afterward, 
and  the  patient  died  on  the  third  day. 

PeneteatesG  "Wounds  of  Joints,  and  non-penetrating 
contused  wounds,  are  always  serious.  They  may  result  in 
synovitis,  complete  or  partial  anchylosis,  or  loss  of  the  whole 


WOUNDS  OF  IMPORTANT  ORGANS.  63 

limb.  Tlie  joint  is  known  to  be  perforated  by  the  appear- 
ance of  a  tliick,  transparent  fluid  (synovia)  from  the  joint. 
This  may  be  absent  wlien  the  wound  passes  into  the  part 
from  above  downward. 

Treatment. — If  the  wound  is  small,  the  edges  should  be 
drawn  together  as  closely  as  possible  and  held  in  close  ap- 
position by  adhesive  plaster.  Ice-bags,  applied  afterward, 
may  prevent,  or  at  all  events  modify,  the  amount  of  inflam- 
mation. Large  wounds  should  not  be  entirely  closed.  In- 
flammation of  the  joint  is  an  invariable  accompaniment, 
and  a  space  must  be  left  through  which  the  discharges  may 
pass. 

Gunshot- Wounds. — Under  this  head  are  included  all 
wounds  which  result  from  the  explosion  of  gunpowder. 
They  may  be  made  with  bullets,  cannon-balls,  or  splinters 
of  wood  and  stone.  The  worst  wounds  are  those  inflicted 
by  cannon-projectiles  and  splinters. 

All  gunshot-wounds,  whether  external  or  internal,  are 
attended  with  danger.  A  greater  amount  of  shock,  contu- 
sion, and  laceration,  accompanies  gunshot-wounds  than  is 
found  in  other  varieties.  Inflammation  and  suppuration 
follow  in  the  track  of  the  bullet.  Pus  is  liable  to  be  re- 
tained and  burrow  in  the  neighboring  tissues.  Deep  suppu- 
ration is  one  of  the  principal  dangers.  The  wound  made 
by  the  bullet  is  smaller  where  it  enters  than  where  it  leaves 
the  body,  and  its  edges  are  inverted,  while  at  the  point  of 
exit  the  edges  of  the  wound  are  everted.  A  bullet  is  easily 
driven  out  of  its  course  by  bony  projections.  The  missile 
may  strike  a  rib  on  the  left  side,  and,  passing  under  the 
tissues,  emerge  on  the  right  side  of  the  body.  Henner 
relates  a  case  where  the  bullet  entered  the  upper  portion 


G4      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

of  the  arm  and  passed  down  to  the  thigh  on  the  opposite 
side. 

Treatment. — The  first  efforts  of  the  surgeon  are  directed 
to  control  the  haemorrhage,  and  to  arouse  the  patient  from 
the  state  of  collapse  by  stimulants.  When  this  is  done, 
foreign  bodies,  such  as  pieces  of  clothing,  bullets,  splinters 
of  wood  or  bone,  are  to  be  extracted.  The  presence  of  a 
bullet  may  be  made  out  in  deep  wounds  by  the  use  of  N^- 
laton's  probe.  This  instrument  consists  of  a  silver  shaft  and 
a  bulbous  extremity  formed  of  porcelain.  When  the  bullet 
is  touched  a  leaden-colored  mark  is  produced  on  the  porcelain. 
The  wound  is  afterward  syringed  with  a  weak  solution  of 
carbolic  acid,  and  covered  with  cloths  dipped  in  an  ice- water 
solution  of  the  acid.  Ice-bags  are  then  found  serviceable  in 
limiting  the  amount  of  inflammation.  When  suppuration 
commences,  warm  fomentations  may  be  used  to  hasten  its 
progress,  and  the  debris  prevented  from  remaining  by  fre- 
quent syringing.  In  the  suppurative  stage,  there  is  great 
danger  from  secondary  haemorrhage.  Therefore,  when  the 
wound  is  in  the  vicinity  of  large  vessels,  it  should  be  care- 
fully watched,  and  a  compress  or  tourniquet  should  be 
placed  loosely  around  the  limb,  ready  to  be  used  at  a 
moment's  warning. 

Gunshot-wounds  of  viscera  are  treated  in  the  same  man- 
ner that  ordinary  wounds  are  after  extraction  of  foreign 
bodies. 


CHAPTER  V. 

W0UMD8  OF  AETEBIES  AND  VEINS. 

Ligation  of  large  Arteries. — Air  in  Veins,  etc. — Causes  of  Sudden  Death.— 

Treatment. 

When  large  vessels  are  wounded,  there  is  a  great  and 
immediate  danger  to  life.  The  blood  may  be  poured  out 
externally,  or  become  diffused  in  the  tissues  near  the  artery, 
or  dissect  up  the  sheath  of  the  vessel.  Efforts  should  in 
every  case  be  made  to  tie  both  ends  of  the  bleeding 
artery  in  the  wound.  {See  article  on  Haemorrhage.)  If 
this  cannot  be  done,  the  artery  is  then  tied  between,  the 
wound  and  the  heart.  Ligature  of  large  vessels  is  generally 
followed  by  complete  obliteration  of  their  canals.  The 
ligature  divides  the  middle  and  internal  coats,  and  brings 
the  external  walls  together.  The  blood  coagulates  at  each 
end  of  the  ligature.  The  coloring  matter  of  the  clot  is 
absorbed.  Lymph  is  poured  out  between  each  coat  of  the 
artery,  between  the  clot  and  the  lining  membrane,  and  ex- 
ternal to  the  vessels,  blending  all  these  parts  together,  and 
becoming  ultimately  a  fibrous  cord.  The  ligature,  mean- 
while, makes  its  way  out  by  a  process  of  ulceration,  and  the 
space  formerly  occupied  by  it  is  filled  up  by  granulation. 
From  ten.  to  fourteen  days  after  the  operation  the  ligature 
comes  away,  and  then  there  is  the  greatest  danger  of  sec- 
ondary haemorrhage. 
5 


QQ  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

As  wounds  may  involve  any  of  the  arteries  in  tlie  body, 
a  sliort  description  of  the  operation  in  diflerent  locations, 
upon  important  arteries,  will  be  necessary  in  this  connec- 
tion. 

In  wounds  of  the  common  carotid  or  subclavian,  it  may 
be  necessary  to  place  a  ligature  on  the  arteria  innominata,  an 
operation  rarely  attended  with  success. 

"When  the  patient  is  fully  anaesthetized  and  in  position, 
an  incision  about  two  inches  in  length  is  made  along  the 
inner  edge  of  the  stcrno-mastoid  muscle  to  the  articula- 
tion of  the  clavicle  with  the  sternum,  meeting  it  with  a 
second  incision  commencing  about  half  an  inch  from  the 
posterior  border  of  the  same  muscle,  and  carrying  it  along 
the  clavicle.  When  the  integument  is  turned  back,  the  pla- 
tysma  myoides  and  sterno-mastoid  muscles  are  divided  on  a 
director,  the  platysma  being  first  cut.  The  handle  of  the 
scalpel  is  now  used  to  push  aside  some  thick  cellular  tissue, 
and  the  sterno-thyroid  and  thyro-hyoid  muscles  are  brought 
into  view  and  carefully  divided.  A  plexus  of  veins,  com- 
posed principally  of  branches  of  the  inferior  thyroid,  next 
appears,  and  must  be  moved  upward  and  kept  out  of  the 
way.  A  thick  layer  of  deep  cervical  fascia  is  next  incised ; 
the  fingers  can  now  be  carried  down,  using  the  common 
carotid  as  a  guide,  until  the  arteria  innominata  is  reached. 
This  vessel  is  situated  behind  the  right  sterno-clavicular  ar- 
ticulation of  the  right  side.  The  right  vena  innominata,  in- 
ternal jugular  vein,  and  pneumogastric  nerve,  are  displaced 
to  the  right,  and  the  left  vena  innominata  pressed  downward 
and  to  the  left.  An  aneurism-needle,  armed  with  a  liga- 
ture, is  then  passed  around  the  vessel  from  below  upward. 

The  common  carotid  artery  is  ligated  either  above  oi 


WOUNDS    OF  ARTERIES  AND   VEINS.  67 

below  the  orao-hyoid  muscle.  When  the  vessel  is  ligated 
above  the  omo-hyoid,  an  incision  is  made  from  the  angle  of 
the  jaw  to  the  cricoid  cartilage.  This  incision  is  carried 
three  inches  farther  than  this  point  when  the  artery  is  tied 
below  that  muscle.  The  inner  edge  of  the  sterno-mastoid 
is  the  guide  for  both  incisions.  The  integument,  superfi- 
cial fascia,  platysma,  and  deep  fascia,  are  cut  through  (the 
three  latter  on  a  director) ;  the  descendens-noni  nerve  is 
moved  aside,  and  the  sheath  of  the  vessels  lifted  with  a  for- 
ceps and  opened.  The  internal  jugular  vein  swells  up  in 
the  wound  as  the  sheath  is  cut ;  it  should  be  compressed 
above  and  below  the  opening,  and  drawn  outwdrd.  The 
pneumogastric  nerve  is  situated  here  between  the  artery 
and  vein,  and  on  a  plane  posterior  to  both,  and  great  care  is 
necessary  to  avoid  it  in  passing  the  ligature.  The  needle  is 
carried  from  without  inward  around  the  artery.  In  ligating 
the  carotid  on  the  left  side  in  its  lower  portion,  the  jugular 
vein  will  be  found  to  have  altered  its  relation  to  the  artery. 
Instead  of  lying  external  to  it,  it  crosses  in  front  of  it. 
Another  point  to  be  remembered  in  connection  with  the  op- 
eration below  the  omo-hyoid  is,  that  the  sterno-mastoid  ar- 
tery and  the  middle  thyroid  vein  run  along  in  the  course  of 
the  incision,  and  must  be  avoided.  The  sterno-thyroid  and 
sterno-hyoid  are  drawn  toward  the  median  line  of  the  neck. 
Ligation  of  the  common  carotid  arteries  is  sometimes  fol- 
lowed by  hemiplegia. 

The  subclaman  artery  is  usually  ligated  in  the  third 
portion.  In  this  operation  the  shoulder  is  depressed  as 
much  as  possible,  the  integument  drawn  down  on  the  clavi- 
cle, and  an  incision  made  through  it,  extending  from  tlie  an- 
terior margin  of  the  trapezius  to  the  posterior  border  of  the 


68  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Bterno-inastoid.  The  fascia  and  platysma  having  been  di- 
vided, the  external  jugular  vein  is  seen  near  the  edge  of  the 
sterno-mastoid  muscle,  and  the  supra-scapular  and  transver- 
salis  colli  nerves  and  vessels  running  across  the  space. 
These  are  pushed  aside,  the  deep  fascia  scratched  through, 
and  the  finger  of  the  operator  carried  along  the  edge  of  the 
scalenus-anticus  muscle  to  the  tubercle  of  the  first  rib,  at 
which  j)oint  the  subclavian  arterj  -will  be  found.  The  aneu- 
rism-needle is  carried  around  the  vessel  from  before  back- 
ward, and  the  ligature  tied. 

Tlie  third  portion  of  the  axillary  artery  is  the  most  con- 
venient part  for  ligation.  An  incision  is  made  about  two 
inches  in  length,  over  the  head  of  the  humerus,  near  the 
centre  of  the  axillary  space.  The  integument  and  fascia 
are  cut  through,  the  axillary  vein  drawn  inward,  the  median 
nerve  outward,  and  the  ligature  passed  from  within  out- 
ward. 

The  hracMal  artery^  in  the  upper  part  of  its  course,  is 
exposed  by  cutting  through  the  integument  and  fascia  at 
the  inner  margin  of  the  coraco-brachialis  muscle.  The  ulnar 
and  internal  cutaneous  nerves,  which  lie  at  the  inner  side  of 
the  artery,  and  the  median  nerve,  which  is  situated  exter- 
nally, are  separated  from  the  vessel,  and  the  ligature  applied. 

The  brachial  may  also  be  tied  at  the  bend  of  the  elbow. 
The  incision  is  made  at  the  inner  border  of  the  biceps  mus- 
cle. At  this  joint  the  artery  lies  internal  to  the  tendon, 
with  the  median  nerve  still  farther  inside,  close  to  the  ves- 
sel. The  median  basilic  vein  passes  over  the  artery,  separated 
from  it  by  the  bicipital  fascia. 

The  radial  artery  should  not  be  tied  at  its  upper  por- 
tion, because  of  its  depth  from  the  surface.     In  the  middle 


WOUNDS   OF  ARTERIES  AND  VEINS.  69 

tliird  it  is  exposed  by  cutting  along  the  inner  margin  of  the 
supinator  longus.  The  radial  nerve,  a  continuation  of  the 
muscle  spiral,  is  found  in  close  relation  with  it  externally. 
The  ligature  is  passed  from  the  radial  to  the  ulnar  side. 

In  the  lower  portion  of  the  forearm,  the  artery  is  found 
between  the  flexor  carpi  radialis  and  supinator  longus.  It 
is  superficial  at  this  point,  and  easily  tied  by  cutting  between 
those  two  muscles. 

The  ulnar  artery,  in  its  lower  portion,  is  located  between 
the  flexor  carpi  ulnaris  and  the  flexor  sublimis  digitorum. 
The  ulnar  nerve  is  found  at  the  inner  side  of  the  former 
muscle.  The  incision  is  carried  through  the  inteorument  and 
fascia  between  these  muscles,  and  the  artery  tied. 

WoTJJSTDS  OF  THE  Paliviak  Aech  are  difficult  to  manage, 
owing  to  the  numerous  anastomoses  of  the  arteries.  The 
hsemorrhage  may  persist  after  ligation  of  the  ulnar,  radial, 
and  brachial  arteries.  Some  surgeons  keep  a  compress  on 
the  wound  for  two  or  three  days,  and,  if  this  does  not 
succeed,  ligate  the  vessels  in  the  forearm  or  arm.  When 
compression  fails,  the  bleeding  vessels  should  be  tied  in 
the  wound,  if  possible. 

Ligation  of  the  femoral  artery  is  commonly  performed 
in  the  lower  portion  of  "Scarpa's  space."  The  integu- 
ment and  fascia  are  divided  at  the  inner  margin  of  the 
Sartorius  muscle.  After  the  sheath  is  opened,  the  femoral 
vein  will  be  found  at  the  inner  side  of  the  artery.  The 
ligature  is  carried  around  from  within  outward. 

After  ligation  of  the  femoral  artery,  the  limb  should 
be  encased  in  a  thick  roll  of  cotton,  to  keep  up  its  nor- 
mal temperature,  until  the  collateral  circulation  is  estab- 
lished. 


70       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Ligation  of  the  po^yliteal  artenj. — This  vessel  is  rarely 
tied  except  for  wounds  whicli  involve  its  "walls.  In  the 
upper  third  of  the  artery  the  operation  is  performed  by 
cutting  the  integument  and  fascia,  at  the  edge  of  the  semi- 
s' membranous.  The  muscle  is  drawn  inward  and  the  artery 
exposed.  Tlie  popliteal  vein  is  external,  and  superficial  to 
the  artery,  and  the  internal  popliteal  nerve  external  and 
superficial  to  the  vein. 

In  the  lower  third,  the  incision  is  made  in  the  median 
line,  immediately  behind  the  joint.  The  deep  fascia  is  here 
very  thick,  and  there  is  considerable  cellular  tissue  around 
the  vessels,  whicli  requires  some  time  and  trouble  to  clear 
away,  so  as  to  bring  them  into  view.  TThen  this  has  been 
done  the  limb  is  flexed,  and  the  needle  passed  around  the 
artery  from  without  inward. 

The  anterior  tilial  artery  is  usually  tied  in  its  lower 
portion  above  the  ankle-joint.  The  artery  is  here  found 
between  the  tibialis  anticus  and  extensor  proprius  pollicis, 
and  is  covered  by  the  integument  and  fascia.  These  latter 
are  incised — the  tendons  separated,  and  the  artery  exposed. 
The  nerve  is  in  this  situation  superficial  to  the  artery.  The 
venae  comites  are  separated  from  each  side  of  the  vessel, 
and  the  ligature  applied  in  the  usual  manner. 

Posterior  tibial. — It  is  extremely  diflBcult  to  reach  this 
artery  in  its  middle  third,  because  of  its  depth  from  the 
surface.  The  operation  is  performed  by  extending  the  foot, 
making  an  incision  at  the  inner  border  of  the  tibia  about 
three  inches  in  length.  When  the  integument  and  fascia 
have  been  cut,  the  edge  of  the  gastrocnemius  muscle  is 
turned  aside,  and  the  soleus  detached  from  the  tibia  by 
cuttins:  its  fibres  on  a  director.     The  fascia  underneath  this 


WOUNDS  OF  ARTERIES  AND  VEINS.  ^1 

muscle  is  next  divided,  and  tlie  artery  exposed  from  three- 
quarters  of  an  inch  to  an  incli  from  the  inner  border  of  the 
tibia. 

The  tibial  nerve  in  this  region  is  situated  on  the  outside 
of  the  artery,  and  should  be  separated  from  the  vessel  before 
tying. 

The  vessel  is  sometimes  tied  as  it  passes  around  the  ankle, 
by  making  a  curved  incision  midway  between  the  internal 
malleolus  and  the  heel.  The  integument  and  superficial 
fascia  having  been  divided,  the  needle  is  passed  from  with- 
out inward,  as  in  the  previous  case. 

Wounds  of  Yeins,  Enteajstce  of  Air. — Fatal  haemor- 
rhage takes  place  in  a  short  time  when  large  veins,  as  the 
jugular  or  vena  innominata,  are  wounded,  unless  immediate 
assistance  is  rendered,  and  the  wound  closed  by  ligation  or 
pressure.  In  wounds  of  small  veins  the  danger  from  haemor- 
rhage is  slight. 

"Wounds  of  veins  may  be  followed  by  phlebitis  or  by  the 
entrance  of  air.  The  latter  complication  occurs  particularly 
in  the  veins  of  the  upper  extremity  and  neck,  during  opera- 
tions for  the  removal  of  tumors.  The  air  enters  the  open- 
ing in  the  vein  with  a  loud  hiss,  and  the  patient,  in  many 
cases,  expires  instantly.  If  only  a  small  quantity  of  air  enter, 
there  is  a  tendency  to  syncope,  difficult  breathing,  and  con- 
vulsive movements  of  the  body,  which  may  last  for  several 
hours  before  a  fatal  termination  is  produced.  In  the  majority 
of  cases  sudden  death  ensues. 

A  number  of  explanations  have  been  offered  to  account 
for  the  suddenness  of  death  in  this  accident.  Bell  thought 
it  due  to  the  action  of  air  upon  the  medulla  oblongata. 
Moore  ascribed  it  to  ii-resrular  action  of  the  valves  of  the 


72       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

heart  from  the  presence  of  air ;  *  others,  again,  ascrihed  it 
to  the  impossibility  of  a  frothy  liquid  passing  through  the 
lungs. 

In  the  absence  of  any  accepted  theory,  I  would  suggest 
the  following :  In  the  great  majority  of  cases  the  accident 
occm's  in  removing  tumors  from  the  neck  or  axillary  region. 
These  tumors  by  their  pressure  empty  the  veins  upon  which 
they  lie.  As  the  knife  of  the  surgeon  passes  into  the  vein, 
and  the  weight  of  the  tumor  is  removed,  air  rushes  in  to  fill 
up  the  vacuum,  and  the  heart  ceases.  When  it  is  consid- 
ered that  the  pressure  of  the  atmosphere  is  equal  to  fifteen 
pounds  to  the  square  inch,  and  the  force-pump  action  of  the 
heart  only  thirteen  pounds  and  a  half  to  the  square  inch,  it 
will  he  seen  that  the  column  of  air  by  its  own  direct  press- 
ure is  suflScient  to  overcome  and  paralyze  the  muscular 
force  of  the  heart.  The  stoppage  is  instantaneous.  Subse- 
quent pressure  on  the  wound  fails  to  do  good,  because  of 
the  presence  of  air  in  the  heart,  which  cannot  be  disposed 
of  with  sufficient  rapidity  to  enable  the  organ  to  recover 
itself.  The  distention  of  the  right  side  of  the  heart,  which 
is  usually  found  after  deatli,  is  accounted  for  on  these 
grounds. 

When  only  a  small  portion  of  air  enters,  and  pressure  is 
made  on  the  wounded  vein,  there  is  sometimes  recovery. 

Whenever  operations  are  performed  about  the  neck  or 
axilla,  every  vein  in  the  vicinity  of  the  surgeon's  knife  should 
be  closed  by  assistants.  Both  before  and  after  the  removal 
of  the  tumor,  this  precautionary  measure  is  called  for. 

Treatment. — Immediate  efforts  to  restore  the  respiratory 
movements,  and  with  tliem  the  action  of  the  heart,  should 

*  Holmes's  Surgery,  article  Wounds  of  Veins. 


WOUNDS  OF  ARTERIES  AND  VEINS.  73 

be  made.  Marshall  Hall's  or  Sylvester's  methods  of  arti- 
ficial respiration  can  be  tried.  Stimulant  enemata  and 
friction  of  the  surface  are  always  necessary.  Galvanism 
may  also  be  tried.  In  mild  cases,  brandy  and  ammonia 
may  be  given  by  the  stomach.  Hot  plates  over  the  epi- 
gastric and  precordial  regions  are  also  serviceable. 


CHAPTER  yi. 

POISONED     WOUNDS. 
Dissecting  Wounds. — Hydrophobia. — Snake-Bites. — Insect-Bites. 

Dissecting  Wouxds. — Dm*ing  the  process  of  putrefaction 
a  poison  is  generated  wliicli  is  capable  of  exciting  inflamma- 
tion in  healthy  tissues,  and  of  reproducing  itself  in  the  cir- 
culation, giving  rise  to  serious  constitutional  disturbances. 
The  poison  is  introduced  by  cutting  or  j)uncturing  the  flesh 
with  the  knife  used  during  the  progress  of  fost-mortem  ex- 
aminations, or  in  the  anatomical  investigations  of  the  dis- 
secting-room. Wounds  of  the  most  serious  character  may 
be  made  by  a  piece  of  broken  rib  or  other  rough  bone. 

"When  putrefaction  is  much  advanced,  the  system  is  less 

Jikely  to  be  infected.   '  It  is  an  established  fact  that  wounds 

/  \  jinflicted  in  the  dissecting-room,  when  decomposition  is  near- 

/  (^  'ly  at  its  maximum,  are  comparatively  harmless,  while  those 

inflicted  in  a  ])08t-riiortein  examination  often  destroy  life. 

^    "Whether  the  material  injected  in  the  arteries  of  subjects 

^^     about  to  be  dissected  modifies  the  poison  or  not,  is  a  subject 

for  future  investigation. 

The  disease  with  which  the  patient  died  has  much  to  do 
with  the  severity  of  the  disease  in  the  wounded  person. 
Puerperal  fever,  erysipelas,  pyaemia,  typhus,  etc.,  are  pecu- 


POISONED  WOUNDS.  75 

liarlj  dangerous.  They  seldom  fail  to  produce  either  local 
or  constitutional  poisoning.  On  the  other  hand,  parturient 
women  are  sometimes  infected  by  the  poison  of  the  dissect- 
ing-room carried  on  the  hands  of  a  physician.  Erysipelas, 
puerperal  fever,  etc.,  are  not  ^infrequently  developed  in  this 
manner. 

Debilitated  states  of  the  system  are  favorable  to  the  in- 
fection. The  influence  of  the  poison  is  more  strongly  mani- 
fested in  every  case  where  the  constitution  is  below  par. 

In  merely  local  poisoning,  the  wound  shows  little  ten- 
dency to  heal,  closing  for  a  day  or  two  and  then  breaking 
out  afresh.  Around  the  wound  the  integument  is  thick- 
ened, and  of  a  dusky  hue.  There  is  an  exudation  from  the 
cut  surface,  of  a  sero-purulent  character.  This  condition  of 
the  wound  may  last  for  weeks,  and  even  months,  healing 
partially  for  a  time,  then  breaking  out  and  assuming  its 
original  unhealthy  appearance. 

In  another  variety  the  wound,  after  a  lapse  of  twenty-four 
or  thirty-six  hours,  becomes  hot  and  painful.  A  small  quan- 
tity of  sanious  fetid  pus  exudes  from  the  surface.  The  sur- 
rounding integument  is  red  and  swollen.  In  a  short  time, 
small  red  lines  may  be  noticed  running  up  the  arm,  indicat- 
ing the  extension  of  inflammatory  action  to  the  lymphatic 
vessels  {angeioleucitis).  The  arm  is  swollen  and  painful. 
The  axillary  glands  enlarge  and  often  suppurate.  Abscesses 
may  form  and  burrow  in  the  cellular  tissues  of  the  arm  and 
chest.  The  skin  is  hot  and  dry,  the  pulse  rapid,  and  urine 
scanty  and  high-colored.  When  the  abscesses  open  and  dis- 
charge, great  prostration  ensues,  which  may  destroy  the  life 
of  the  patient  or  leave  him  a  helpless  invalid  for  months. 

The  third  class  of  cases  rarely  recover.     The  patient. 


76       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

within  a  period  ranging  from  twenty-fonr  to  forty-eigLt  liours 
after  the  wound  is  received,  is  seized  with  violent  chills. 
These  are  succeeded  by  unmistakable  evidences  of  blood- 
poisoning.  The  pulse  becomes  rapid  and  very  small,  the 
countenance  anxious,  and  tongue  brown  and  dry.  The  in- 
tegument is  of  a  tawny  color,  and  may  be  jaundiced.  There 
is  profuse  perspiration.  Meanwhile,  the  wound  becomes 
very  painful ;  the  tissues  around  it  are  thickened  and  infil- 
trated with  pus.  Abscesses  are  not  confined  to  the  injured 
tissue,  but  may  show  themselves  in  any  part.  The  lym- 
phatics are  involved  as  in  the  preceding  case.  Delirium  sets 
in,  and  is  soon  followed  by  death.  In  severe  cases,  death 
may  occur  within  forty-eight  hours  after  the  infliction  of  the 
injury. 

Treatment. — In  wounds  of  this  character,  proper  pre- 
cautions should  be  immediately  resorted  to  in  order  to  pre- 
vent the  retention  of  the  poison  and  its  subsequent  entrance 
into  the  circulation.  The  wound  should  be  washed  by  hold- 
ing it  under  a  stream  of  water  for  a  few  seconds.  The  lips 
are  then  applied  and  the  virus  removed  by  suction.  There 
is  no  necessity  for  the  application  of  caustics. 

The  treatment  of  cases  where  there  is  only  local  poison- 
ins:  resolves  itself  into  stimulation  of  the  wound  bv  means 
of  carbolic-acid  or  nitrate-of-silver  solutions,  and  maintain- 
ing the  health  of  the  patient  at  a  proper  standard,  by  fresh 
air,  good  food,  and  tonic  medicines. 

In  those  cases  where  acute  inflammation  appears  in  the 
wound  and  extends  to  neighboring  tissues,  the  wound  should 
be  enlarged  and  cleansed  of  accumulations  of  pus  with  a 
strong  solution  of  carbolic  acid.  A  poultice  of  linseed-meal 
and  charcoal  may  be  then  applied  to  the  wound,  and,  if 


POISONED  WOUNDS.  Y7 

necessary,  to  the  wliole  limb.  PaintiDg  the  inflamed  lym- 
phatic vessels  "with  iodine  has  been  recommended. 

Opium  is  freely  given  to  relieve  pain  and  to  produce 
sleep.  Easily-digested  nutriment,  such  as  beef-tea  and 
chicken-broth,  is  to  be  administered  ad  lilAtum.  Stimu- 
lants are  sometimes  necessary.  The  treatment  for  the  third 
variety  is  similar,  with  the  addition  of  stimulants  used  freely, 
and  large  doses  of  quinine. 

Hydeophobia. — Phobodipson,  rabies,  canine  madness, 
]yssa,  and  a  variety  of  other  terms,  have  been  used  to  desig- 
nate this  malady.  It  has  been  known  from  the  earliest  his- 
torical periods.  The  disease  attacks  man  and  many  of  the 
lower  animals.  Dogs,  cats,  and  wolves,  are  most  subject  to 
its  ravages.  Cows,  goats,  pigs,  and  horses,  are  occasionally 
afflicted.  It  occurs  at  all  seasons  of  the  year,  without  refer- 
ence to  climate  or  temperature,  appearing  in  the  winter 
season  as  well  as  in  "  dog-days."  The  nature  of  the  poison 
is  unknown.  It  is  transmitted  from  one  animal  to  another 
by  means  of  the  salivary  secretions  introduced  through 
wounds  inflicted  by  the  teeth.  Other  secretions  in.  the  body 
are  said  to  be  harmless  and  unable  to  transmit  the  disease. 

The  period  between  the  inoculation  and  the  develop- 
ment of  the  disease  is  subject  to  considerable  variation. 
Generally  it  appears  between  one  and  two  months.  Cases 
have  been  recorded  (hardly  with  sufficient  authority,  how- 
ever, to  establish  them  as  facts)  where  the  disease  remained 
latent  for  twelve  or  fifteen  months. 

Billroth  mentions  an  old  superstition  which  attaches 
great  importance  to  the  number  nine,  and  gives  the  disease 
a  tendency  to  develop  on  the  ninth  day,  ninth  week,  or 
ninth  month,  succeeding  the  injury. 


78       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Rabies  in  the  Jog  is  divided  by  Virchow  into  three  stages : 
1.  The  melancholic;  2.  Furious;  and  3.  Paralytic.  The 
animal  affected  loses  its  appetite — shrinks  from  water  and 
ordinary  food — endeavors  to  hide  in  his  kennel,  and  can 
with  great  difficulty  be  coaxed  out.  The  head  droops,  and 
the  eyes  are  bloodshot  and  heavy.  There  is  great  thirst,  and 
water  is  not  refused. 

In  the  second  stage  the  animal  yelps  or  howls,  and  runs 
wildly  about,  biting  at  every  thing.  The  tongue  hangs  from 
the  mouth,  and  the  eyes  are  congested  and  wild. 

In  the  third  stage  emaciation  is  apparent  and  rapidly 
progresses,  great  exhaustion  supervenes.  Little  effort  is 
made  to  move,  and  the  saliva  dribbles  from  the  mouth.  In 
walking,  both  hind-legs  are  dragged  on  the  ground  as  if 
paralyzed.  Death  ensues  in  from  four  to  eight  days  from 
the  commencement  of  the  disease. 

Hydrophobia  in  man  has  many  of  the  characteristics 
just  described. 

A  person  bitten  by  a  mad  dog  is  usually  on  the  watch 
for  some  manifestation  of  the  disease.  The  wound  may 
heal  readily,  but  the  dread  remains.  If  the  cicatrix  begins 
to  inflame  and  is  painful,  and  other  signs  appear  which 
show  that  his  fears  are  about  to  be  realized,  the  depression 
of  spirits  and  anguish  are  intensified.  All  cases  are  pre- 
ceded and  accompanied  by  this  terror.  It  is  one  of  the  char- 
acteristics of  hydrophobia. 

As  the  disease  progresses,  the  skin  becomes  hot  and  dry, 
the  pulse  rapid,  and  lacking  strength.  There  is  much  thirst. 
In  two  or  three  days  from  the  first  manifestation  of  the 
disease  the  muscles  of  the  throat,  and  especially  those  con- 
cerned in  deglutition,  become  stiff  and  sore.     Attempts  at 


POISONED  WOUNDS,  79 

Bwallowing  are  followed  by  spasmodic  contraction  of  these 
muscles,  and  of  those  concerned  in  respiration.  These  con- 
vulsive movements  increase  in  frequency,  excited  by  the 
smallest  provocation.  Slamming  doors,  cold  currents  of  air, 
pouring  water  from  one  vessel  to  another,  or  changing  the 
bedclothes,  brings  them  on.  In  some  cases  there  are  general 
convulsions.  Thirst  is  intense,  and  the  unfortunate  patient 
does  not  relieve  it  for  fear  of  choking  or  renewing  the 
spasms.  Sometimes  there  are  small  j)ustules  under  the 
tongue  (Marschetti).  The  patient's  countenance  expresses 
all  his  terror.  The  eyes  are  staring  and  bloodshot.  A  thick 
saliva  is  constantly  thrown  from  the  mouth.  The  voice  is 
husky.  As  the  end  approaches,  the  skin  becomes  cold  and 
clammy,  the  pulse  almost  imperceptible,  and  the  resj^ira- 
tory  movements  irregular.  A  convulsion  may  terminate 
life  by  involving  the  muscles  of  respiration,  or  the  patient 
may  die  gradually  from  exhaustion. 

After  death,  the  fauces,  throat,  and  lungs,  are  dark-colored 
and  congested.  In  some  cases,  there  are  congestion  of  the 
cord  and  effusion  into  the  ventricles  of  the  brain.  There 
is  nothing  definite  in  any  of  the  lesions  to  indicate  the 
Bpecific  action  of  the  virus. 

Strange  as  it  may  seem,  hydrophobia  is  sometimes  imitated 
for  mercenary  purposes.  A  case  of  this  kind  was  admitted 
to  Ward  9,  Bellevue  Hospital,  in  the  winter  of  1867.  The 
patient  stated  that,  when  seven  years  of  age  (he  was  then 
twenty-five),  he  was  bitten  by  a  mad  dog.  One  year  after- 
ward, symptoms  of  hydrophobia  manifested  themselves. 
He  recovered  from  that  attack,  but  exactly  one  month 
afterward  at  "  the  full  of  the  moon,"  he  was  affected  in  a 
similar  manner.     This  peculiar  tendency  to  a  monthly  re- 


so       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

currence  kept  up  for  two  or  three  years,  and  then  ceased  up 
to  within  two  years  of  his  first  appearance.  At  that  time 
they  again  commenced,  and  had  continued  at  irregular  in- 
tervals until  his  admission  to  the  hospital. 

While  in  the  reception-room,  awaiting  transference  to 
the  ward,  an  orderly  approached  him  with  some  water,  which 
immediately  threw  him  into  a  convulsion.  lie  writhed 
violently  on  the  floor,  throwing  the  arms  and  legs  ahout  in 
every  direction.  Tlie  saliva  collected  in  the  form  of  foam 
around  his  mouth,  and  he  howled  and  yelped  like  a  "  mad 
dog."  The  convulsion  lasted  for  two  minutes.  At  its  ter- 
mination he  seemed  to  be  quite  exhausted,  but  was  able  to 
walk  to  the  ward. 

Shortly  after  his  admission,  and  while  in  a  convulsion, 
he  was  seen  by  Dr.  Flint,  who  advised  the  application  of 
hot  water  to  the  skin.  The  patient  did  not  wait  for  the 
remedy,  but  recovered  immediately.  Finally,  after  a  close 
questioning,  he  confessed  the  fraud,  and  admitted  that  for 
many  years  he  had  practised  the  game  successfully,  making 
considerable  capital  out  of  it. 

This  man's  story  was  told  with  such  an  appearance  of 
candor,  that  it  was  hard  to  doubt  at  least  his  own  faith  in 
the  reality  of  the  disease. 

Treatment. — A  wound  inflicted  by  a  dog  suspected  of 
madness  should  be  washed  and  sucked  as  in  ordinary  dis- 
secting wounds,  and  afterward  thoroughly  cauterized 
Complete  excision  of  the  part  is  better,  in  most  cases,  than 
destroying  the  tissues  by  cauterization.  Previous  to  the 
washing  and  excision,  some  recommend  that  a  ligature  be 
placed  tightly  around  the  limb,  above  the  wound,  in  order 
to  prevent  absorption  of  the  poison.     On  the  arm  or  leg  the 


POISONED  WOUNDS.  81 

procedure  is  useless,  because  the  circulation  tlirongli  the 
deep  veins  cannot  be  completely  stopped.  If  placed  on  the 
fingers  or  toes,  it  may  answer.  In  the  bitten  parts  the  ex- 
cision should  extend  some  distance  into  the  healthy  tissue, 
and  the  wound  be  subsequently  cauterized.  Tlie  actual  cau- 
tery is  the  best,  but  the  most  painful. 

"When  the  disease  is  fully  developed  but  little  can  be  ac- 
complished. Stimulants  can  be  given  in  large  quantities 
by  enema,  and  other  liquids  in  like  manner.  Opiates  and 
anaesthetics  should  always  be  administered  to  relieve  the 
pain  and  distress,  and  decrease  the  convulsive  movements. 
As  the  wound  has  again  become  inflamed  and  painful,  hot 
disinfecting  poultices,  sprinkled  with  laudanum,  will  be 
serviceable.  Free  discharge  should  be  kept  up  continu- 
ally. 

Snake-Bites. — Among  the  principal  venomous  reptiles 
may  be  enumerated  the  whip-cord  snake,  cobra  de  eapello, 
rattlesnake,  viper,  and  adder.  The  bites  of  the  first  two  pro- 
duce a  fatal  result  more  quickly  than  the  others.  Rattle- 
snake-bites stand  next  in  order  of  virulence.  Yiper  and 
adder  bites  are  fatal  only  to  very  young  animals,  or  to 
children  of  tender  years.  In  the  more  deadly  classes  the 
symptoms  following  a  bite,, and  the  action  of  the  poison,  are 
the  same. 

Rattlesnake-bites  are  not  uncommon  in  the  Southern 
and  Western  States,  and  the  mortality  attending  them  is 
very  great. 

The  venom  of  this  reptile  is  contained  in  a  small  sac 

situated  at  the  base  of  the  sharp  tooth  or  fang.    The  tooth  is 

'  channelled  throughout  its  centre  to  make  a  place  of  exit  for 

the  poison.     "When  the  tooth  is  inserted  into  the  tissues,  the 


S2      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

poison-sac  is  compressed,  and  the  venom  ejected  into  the 
wound. 

The  person  bitten  is  overcome,  either  immediately  or 
after  the  lapse  of  a  few  minutes,  bj  a  feeling  of  faintncss  and 
great  depression.  The  pulse  becomes  feeble,  rapid,  and  in- 
termittent. The  pupils  are  dilated  ;  there  is  some  pain  over 
the  abdomen,  vomiting,  and  sometimes  purging.  Delirium 
is  present  in  most  cases.  The  extremities  and  surftice  of  the 
body  are  cold  and  clammy,  respiration  is  catching  and  diffi- 
cult. Coma  comes  on,  grows  rapidly  deeper,  and  terminates 
in  death. 

The  wound,  shortly  after  the  bite,  swells  rapidly.  In 
one  case  it  assumes  a  dark-red  color,  in  another  a  bluish- 
black.  A  few  patches  of  a  light  color  may  be  intermixed. 
There  is  a  sharp,  intense  pain  in  the  wound,  which  extends 
up  the  limb,  generally  in  the  course  of  the  principal  nerves. 
Inflammation  extends  to  the  neighboring  tissues,  and,  if  the 
patient  live  long  enough,  diffuse  suppuration  may  occur, 
and  abscesses  form  throughout  the  limb. 

Rattlesnake-bites  produce  death  in  from  five  to  ten 
hours.  The  post-mortem  appearances  show  nothing  of  the 
special  effects  of  the  poison.  Sometimes  there  is  congestion 
of  the  brain,  with  serous  effusion  underneath  the  arachnoid 
and  into  the  ventricles.  There  may  also  be  congestion  of 
the  lungs  and  mucous  membrane  of  the  stomach  and  intes- 
tines. The  blood  remains  fluid  in  the  cavities  of  the  heart 
in  many  cases. 

Treatment. — The  wound  should  be  treated  in  precisely 
the  same  manner  as  a  wound  produced  by  the  bite  of  a  mad 
dog;  that  is,  the  part  should  bo  washed,  sucked,  excised,  or 
cauterized. 


POISONED  WOUNDS.  33 

A  vast  number  of  internal  remedies  have  been  proposed. 
Bilron's  antidote  is  one  which  has  been  strenuously  advo- 
cated. Dr.  W.  A.  Hammond,  after  a  series  of  experiments, 
came  to  the  conclusion  that  it  vras  a  remedy  of  great  efScacy. 
Its  formula  is  as  follows  : 

5.   Potassii  iodidi gr.  iv. 

Hydrg.  bichloridi gr.  ij. 

Bromii 3  iv* 

From  ten  to  twenty  drops  of  this  mixture  are  given  every 
half-hour,  uptil  an  amelioration  of  the  symptoms  is  pro- 
duced. 

Arsenic  is  another  remedy  highly  spoken  of.  Guaco, 
Virginia  snakeroot,  and  other  medicines  of  vegetable  origin, 
have  also  acquired  temporary  reputation  as  antidotes.  Tlie 
the  most  efficacious  treatment  is  to  administer  large  doses 
of  carbonate  of  ammonia  repeatedly  in  conjunction  with 
enemata  of  whiskey  or  brandy.  The  ammonia  can  be  ad- 
ministered in  ten  or  twenty  grain  doses  every  half-hour. 
Friction  to  the  surface,  with  hot  pieces  of  flannel  dipped  in 
alcohol,  is  also  beneficial. 

The  poisoned  wounds  produced  by  scorpions,  tarantulas, 
centipedes,  and  other  members  of  this  class,  are  rarely  at- 
tended with  destruction  of  life. 

Scorpions  have  an  elongated  body  and  a  slender  tail,  the 
latter  six-jointed.  In  the  last  joint  there  is  a  sharp  sting, 
which  communicates  with  poison  follicles.  Scorpions  are 
found  in  all  tropical  climates.  The  largest  scorpions  are  the 
most  venomous. 

The  tarantula,  a  species  of  spider  which  inhabits  South- 
ern Europe,  was  at  one  time  held  in  great  terror  on  account 


8i      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

of  its  reputed  deadly  influence.  The  stories  of  its  ravages 
are,  however,  not  founded  on  fact. 

Centipedes  are  less  dangerous  than  either  of  the  pre- 
ceding varieties.  The  most  venomous  grow  to  a  length  of 
six  inches.  A  number  of  poison-claws  project  from  the 
body.  As  the  insect  crawls  over  the  surface,  these  are  in- 
serted into  the  integument,  and  the  virus  introduced.  Some 
writers  deny  the  existence  of  any  special  poison  in  members 
of  this  class. 

The  constitutional  symptoms  following  the  bites  of  these 
insects  are  exhibited  in  the  form  of  lieadache,  vertigo,  dim- 
ness of  vision,  and  sometimes  febrile  excitement.  The 
wound,  in  some  cases,  is  not  inflamed ;  in  others,  it  becomes 
red  and  painful,  and  the  inflammation  spreads  to  other 
parts  of  the  extremity  injured,  ending  in  diffuse  suppuration. 

Treatment. — ^TVhen  the  wound  is  cleansed,  it  should  be 
sponged  thoroughly  with  a  strong  solution  of  ammonia,  and 
afterward  covered  with  cloths  moistened  with  the  same  sub- 
stance. Brandy  may  be  given  internally  in  conjunction 
with  ammonia. 


CHAPTER  YII. 

EXTRACTION  OF  FOREIGN  BODIES. 

Foreign  Bodies  in  the  Larynx,  Trachea,  Broncliial  Tubes,  Pharynx,  CEsoph- 
agus,  Eyes,  Nose,  Ears,  Urethra,  Bladder,  and  Eectum.  —  Tracheotomy. — 
Laryngotomy  Laryngotomy. — (Esophagotomy. 

FoEEiGN  Bodies  m  the  Air-passages. — Foreign  bodies 
are  usually  lodged  in  that  portion  of  the  air-passages  known 
as  the  larynx.  This  organ  is  situated  in  the  median  line  of 
the  neckj  between  the  trachea  and  base  of  the  tongue.  The 
anterior  margin  of  its  superior  opening  is  guarded  by  a  car- 
tilage called  the  epiglottis.  During  the  act  of  deglutition,- 
the  epiglottis  closes  the  aperture  in  the  larynx,  and  prevents 
the  entrance  of  food  as  it  passes  over  on  its  way  to  the 
oesophagus.  It  is  raised  during  the  respiratory  movements 
for  the  free  ingress  and  egress  of  air. 

The  trachea  commences  opposite  the  fifth  cervical,  and 
bifurcates  about  the  third  dorsal  vertebra  into  the  right  and 
left  bronchus.  The  right  bronchus  is  shorter  than  the  left. 
Its  orifice  lies  directly  under  the  tracheal  canal,  so  that  for- 
eign bodies  which  pass  below  the  trachea  drop  in  and  effect 
a  lodgment.  The  endeavor  to  talk,  laugh,  or  respire,  with 
food  or  other  substances  in  the  mouth,  is  often  followed  by 
the  entrance  of  some  portion  into  the  air-passages.  In  talk- 
ing or  laughing,  the  air  is  passing  out  of  the  lungs,  and  the 
epiglottis  is  raised.     Heavy  substances   contained  in  the 


/I- 


86       EMERGEXCIES,  AND  IIOW  TO  TREAT  TUEM. 

mouth  during  these  acts,  readily  roll  backward,  notwith- 
standing the  outward  current.  Taking  a  sudden  inspiration 
while  eating  is  more  dangerous,  as  the  current  of  air  pass- 
ing downward  is  liable  to  sweep  a  portion  of  the  food  along 
with  it.  Vomiting,  while  in  a  state  of  intoxication,  is  apt 
to  be  attended  with  the  entrance  of  half-digested  particles 
of  food  into  the  larynx.  It  is  not  unusual  for  wonns  to  find 
their  way  into  the  larynx  during  sleep,  or  for  bronchial 
glands  to  become  detached  and  carried  upward,  producing 
serious  and  even  fatal  results.  The  presence  of  a  foreign 
body  in  the  pharynx,  or  oesophagus,  may  induce  spasm  of 
the  glottis,  and  lead  to  the  erroneous  supposition  that  it  has 
found  lodgment  in  the  air-passage.  The  introduction  of  a 
probang  will  settle  the  difficulty. 

Children  are  more  often  subjected  to  this  accident  than 
adults  are.  The  habit  of  carrying  in  the  mouth  beads, 
marbles,  or  pennies,  is  very  prevalent  among  them.  As  an 
instance  of  the  dangerous  results  attending  it,  the  following 
incident,  which  occuiTed  in  Bellevue  Hospital,  may  be  of 
interest : 

"While  engaged  in  amputating  the  great-toe  of  a  little 
girl,  who  was  under  the  influence  of  chloroform,  she  sud- 
denly ceased  to  breathe ;  the  face  assumed  a  purple  hue, 
and  death  seemed  imminent.  Apprehending  that  the  chloro- 
form was  the  cause  of  the  difficulty,  I  commenced  artificial 
respiration.  While  I  compressed  the  chest,  my  assistant 
introduced  his  finger  into  the  mouth  to  clear  the  throat  of 
mucus,  and  draw  forward  the  tongue.  In  so  doing  he 
found  a  copper  coin  completely  closing  the  superior  aperture 
of  the  larynx.  The  removal  was  soon  followed  by  a  renewal 
of  the  respiratory  movements,  and  disappearance  of  all  the 


EXTRACTION  OF  FOREIGN   BODIES.  87 

alarming  symptoms.  Tlie  child  had  been  playing  with  the 
penny,  and  had  placed  it  in  her  mouth  previous  to  my 
arrival  in  the  ward,  and,  when  insensibility  was  induced  by 
the  anaesthetic,  it  fell  back  into  the  larynx. 

Foreign  bodies  may  lodge  in  the  upper  part  of  the 
larynx — in  the  ventricle  between  the  vocal  cords,  or  in 
the  trachea  and  bronchial  tubes.  The  symptoms  differ 
with  the  location  of  the  material,  and  the  length  of  time 
it  has  remained. 

The  size  of  the  foreign  body  bears  no  special  relation  to 
the  severity  of  the  symptoms,  unless,  indeed,  it  is  so  large 
as  to  completely  block  up  the  canal.  A  light  substance 
capable  of  being  moved  up  and  down  with  the  respiratory 
movements  occasions  greater  distress  than  one  which  is  sta- 
tionary. "When  the  material  lodges  in  the  larynx,  whether 
large  or  small,  it  produces  a  spasm  of  the  laryngeal  muscles 
which  close  the  glottis,  and  thus  prevents  the  passage  of  air. 
The  patient  struggles  for  breath,  the  lips  and  cheeks  become 
livid  and  swollen,  the  eyes  protrude  from  their  sockets^ 
convulsive  movements  of  the  limbs  accompany  the  agonizing 
efforts  to  breathe,  and  the  patient  dies  at  once,  or  receives 
temporary  relief  from  a  relaxation  of  the  spasms.  The  cur- 
rent of  air  which  now  enters,  either  passes  the  obstruction, 
or  carries  it  farther  down  into  the  trachea.  Once  in  this 
organ,  the  intense  suffocative  symptoms  become  less  marked 
and  continuous.  There  is  more  or  less  difficulty  of  respira- 
tion all  the  time,  pain  over  the  point  where  the  foreign 
body  is  lodged,  and  a  distressing  cough.  The  countenance 
has  an  extremely  anxious  expression ;  the  pulse  is  rapid. 
Severe  dyspnoea  occurs  now  only  at  intervals.  "Whenever 
the  substance  is  forced  up  into  the  larynx,  violent  efforts  at 


S8  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

expulsion  again  ensue,  Avitli  the  same  paroxysm  as  cliar- 
acterizfed  the  first  stage. 

"When  the  foreign  body  reaches  one  of  the  bronchi,  the 
hmg  on  the  corresponding  side  gives  but  little  respiratory 
murmur  on  auscultation,  and  over  the  opposite  lung  there 
are  exaggerated  res])iration  and  increased  resonance  on  per- 
cussion. 

The  presence  of  a  foreign  body  in  an}-  part  of  the  air- 
passages  gives  rise  to  symptoms  like  those  mentioned  above 
— they  only  differ  in  degree.  After  a  day  or  two  has 
elapsed  we  have  more  pain — the  cough  is  increased,  the 
pulse  becomes  accelerated,  the  countenance  retains  its  anx- 
ious expression,  the  voice  is  husky,  and  general  febrile  ac- 
tion is  developed.  There  are  also  the  special  signs  of  in- 
flammation in  the  part  occupied  by  the  irritating  material. 

Death  may  occur  instantaneously  in  the  Jirst  j)eriod, 
from  asphyxia  or  injury  to  the  brain,  from  extravasation  of 
blood  following  the  violent  efforts  to  respire.  In  the  second 
period  death  is  induced  by  bronchitis  or  larjnigitis.  If 
weeks  and  months  elapse  before  its  expulsion,  abscesses  may 
form,  and  the  patient  succumbs  to  exhaustion. 

Treatment. — A  violent  blow  on  the  back,  if  given  im- 
mediately after  the  accident  occurs,  will  assist  the  natural 
efforts  of  the  patient  in  ejecting  the  foreign  body.  After  it 
has  passed  the  larynx,  this  procedure  alone  will  be  of  little 
avail.  If  the  first  attempt  fails,  the  body  is  to  be  inverted 
and  held  up  by  assistants,  while  the .  physician  strikes  with 
the  open  hand  between  the  shoulders,  at  the  same  time 
moving  the  patient  rapidly  from  side  to  side.  If  this 
method  induces  violent  suffocatve  paroxysms,  it  must  not 
be  repeated.     Should  the  urgent  symptoms  continue,  which 


EXTRACTION"  OF  FOREIGN  BODIES.  89 

they  are  liable  to  do,  laryngotomy  or  tracheotomy  must  be 
performed  without  delay.  The  acute  sensibility  of  the 
larynx  hinders  the  irritating  material  from  passing  the 
glottis,  which  closes  spasmodically  every  time  it  reaches 
that  point,  and,  unless  an  opening  is  made  lower  down  to 
give  it  exit,  death  may  soon  ensue.  Some  surgeons  advise 
the  administration  of  emetics,  but  such  practice  is  worse 
than  useless. 

Tracheotomy  is  preferred  above  other  operations  by 
some  practitioners,  especially  for  children ;  but,  if  circum- 
stances admit,  laryngotomy  should  be  first  performed.  It 
possesses  many  advantages  worthy  of  attention  : 

1.  The  parts  are  more  accessible  at  all  periods  of  life. 

2.  It  is  performed  with  greater  rapidity,  and  conse- 
quently is  peculiarly  applicable  to  cases  requiring  instant 
relief. 

3.  There  is  no  danger  of  wounding  important  vessels, 
or  delaying  the  operation  by  hsemorrhage. 

Laryngotomy  is  performed  through  the  membranous  in- 
terval existing  between  the  thyroid  and  curved  cartilages. 
The  region  is  superficial  and  readily  exposed.  The  only 
vessel  to  be  avoided  is  the  crico-thyroid  artery,  which  passes 
across  the  upper  part  of  the  space  to  anastomose  with  its 
fellow  on  the  opposite  side. 

The  patient  should  be  placed  in  a  chair  or  in  the 
recumbent  posture,  with  the  head  thrown  back,  and  the 
larynx  steadied  by  an  assistant.  An  incision  about  an  inch 
in  length  is  made  through  the  integument  over  the  crico- 
thyroid space,  fully  exposing  the  membrane,  which  is  then 
opened  by  a  transverse  cut  near  the  cricoid  cartilage.  By 
keeping  close  to  this  cartilage,  all  danger  of  wounding  the 


90       EMERGEXCIES,  AND  ^0^y  TO  TREAT  TUEM. 

arterv  is  n voided.  The  aperture  thus  made  in  the  larynx  is 
now  widened  by  a  dihxtor  or  ordinary  forceps,  and  the 
patient  turned  on  liis  chest.  If  the  opening  be  too  small, 
the  incision  may  be  carried  down  through  the  cricoid  carti- 
lage and  upper  ring  of  the  trachea. 

The  ejection  of  the  foreign  body  often  occurs  as  soon  as 
the  operation  is  completed,  but,  if  this  desirable  result  do 
not  follow,  and  the  substance  be  within  reach,  a  long-curved 
forceps  may  be  carefully  introduced  to  remove  the  obstruc- 
tion. "When  the  passages  are  entirely  cleared,  the  edges  of 
the  wound  must  be  approximated  and  allowed  to  heal. 

Tracheotomy  requires  greater  care  and  skill  in  its  per- 
formance than  laryngotomy.  The  trachea,  especially  in 
children,  is  deeply  seated,  and  covered  by  important  plex- 
uses of  veins  and  close  proximity  to  large  arteries.  The 
parts  to  be  avoided  in  the  operation  are  :  1.  The  anterior 
jugular  veins.  2.  The  isthmus  of  the  thyroid  gland  which 
lies  on  the  second  and  third  rings  of  the  trachea;  and  3.  The 
inferior  thyroid  veins. 

It  is  always  safe  to  administer  chloroform  to  a  child 
before  commencing  the  operation.  It  renders  material 
assistance  to  the  surgeon,  by  relieving  spasm  and  keeping 
the  patient  from  struggling.  Should  it  be  considered  advis- 
able to  dispense  with  the  anoesthetic,  the  child's  body  must 
be  enveloped  in  a  sheet,  which  will  keep  the  limbs  motion- 
less. The  head  is  thrown  back  in  the  former  case,  and  the 
larynx  held  by  an  assistant.  An  incision  is  made  through 
the  integument  directly  in  the  median  line,  beginning  a 
short  distance  below  the  cricoid  cartilage,  and  continued 
down  from  one  and  a  half  to  two  inches.  By  keeping 
exactly  in  the  median  line  the  anterior  jugular  veins  are 


EXTRACTION  OF  FOREIGN  BODIES.  91 

avoided.  These  vessels  are  pushed  aside,  and  the  incision 
carried  through  tlie  fascia,  which  covers  the  stern o-hyoid 
and  sterno-thyroid  muscles.  These  muscles  are  separated, 
and  the  inferior  thyroid  plexus  of  veins  is  reached.  The 
handle  of  the  scalpel  is  now  to  be  carefully  used  in  getting 
them  out  of  the  way  without  laceration.  A  tenaculum  is 
inserted  into  the  trachea  to  draw  it  forward.  The  knife  is 
introduced  between  the  rings,  and  two  or  three  of  them 
divided  from  below  upward.  The  cut-ends  are  held  apart 
by  ligature  or  widened  by  dilators,  and  the  patient  is  placed 
in  a  supine  posture,  and,  if  the  obstruction  still  remains  and 
is  within  reach,  it  must  be  removed  with  the  forceps. 

When  these  operations  are  performed  for  other  patho- 
logical conditions,  as  laryngeal  inflammations,  tumors  of  the 
larynx,  oedema  glottidis,  croup,  etc.,  a  curved  tube  is  intro- 
duced through  the  opening,  and  allowed  to  remain  until  the 
difficulty  which  called  for  the  operation  is  removed. 

When  the  operation  is  concluded  and  the  tube  inserted, 
the  patient  must  be  carefully  watched  for  a  day  or  two,  and 
the  tube  kept  clear  of  blood  and  mucus.  The  old  form  of 
trachea-tube  necessitated  the  use  of  a  feather  in  order  to 
keep  it  clean  ;  but  the  variety  now  employed  has  a  second 
tube  fitting  closely  inside  the  first,  which  can  be  removed 
and  cleaned  at  pleasure  without  disturbing  the  patient. 

FoKEiGN  Bodies  in  the  Phaeyists  a^td  CEsophagus. — The 
pharynx  is  that  part  of  the  alimentary  canal  which  extends 
from  the  base  of  the  skull  to  the  fifth  cervical  vertebra, 
where  it  becomes  continuous  with  the  oesophagus.  It  lies 
behind  the  nose,  mouth,  and  larynx,  in  the  order  mentioned 
from  above  downward.  Its  widest  part  is  opposite  the 
hyoid  bone,  its  narrowest  portion  ia  where  it  joins  the 


92       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

oesopliagns.  The  food  passes  into  it  from  the  mouth,  and  is 
cai-ried  down  into  the  oesophagus  by  contraction  of  the 
pharyngeal  muscles. 

The  oesophagus  commences  opposite  tlie  cricoid  carti- 
lage, to  which  it  is  attached  by  muscular  fibres,  and  termi- 
nates in  the  cardiac  extremity  of  the  stomach,  on  a  level  with 
the  ninth  dorsal  vertebra.  In  the  neck  it  lies  behind  the 
trachea.  It  measures  nine  inches  in  length,  and  is  the  nar- 
rowest portion  of  the  alimentary  canal ;  the  most  contracted 
parts  are  at  its  origin,  and  as  it  passes  through  the  dia- 
phragm to  connect  with  the  stomach. 

Yarious  foreign  bodies  have  lodged  in  the  oesophagus 
and  pharynx — among  the  most  frequent  of  which  are 
bulky  articles  of  diet,  such  as  meat,  potatoes,  beans,  apples, 
etc.,  and  metallic  substances,  such  as  pennies,  needles,  pins, 
and  nails,  and  even  bones,  false  teeth.  India-rubber,  and 
pieces  of  glass  have  been  found.  The  symptoms  depend  in 
some  degree  on  the  location  and  character  of  the  foreign 
body.  "When  of  large  size,  it  is  apt  to  stop  at  the  lower  por- 
tion of  the  pharynx,  and  by  its  pressure  on  the  larynx  cause 
spasm  of  the  glottis  and  consequent  suiFocative  paroxysms. 
Should  it  pass  below  this  point,  the  pressure  on  the  trachea 
may  still  obstruct  the  entrance  of  air.  After  the  foreign 
body  fully  enters  the  oesophagus,  it  generally  reaches  the 
lower  constricted  portion  at  the  cardiac  orifice  before  it  again 
lodges.  Small  bodies,  such  as  pins  or  needles,  pierce  the 
mucous  membrane,  and  cause  more  pain  and  irritation  than 
other  varieties.  If  they  stop  at  the  lower  anterior  part  of 
the  pharynx,  spasmodic  closure  of  the  glottis  is  induced,  often 
to  a  greater  extent  than  when  bodies  of  a  large  size  press  on 
the  same  part.     Irregular  sharp  substances  in  the  pharynx 


EXTRACTION  OF  FOREIGN  BODIES.  93 

or  upper  end  of  tlie  oesopliagus  cause  nausea  and  vomit- 
ing. 

In  tlie  average  of  eases  there  are  pain  at  the  point  of 
lodgment  or  over  the  episternal  notch,  and  difficulty  of 
swallowing.  The  patient  is  often  extremely  nervous,  and 
complains  of  general  distress  in  the  throat. 

Treatment. — In  all  cases  of  simple  ohstruction  of  the 
pharynx  or  oesophagus,  the  first  endeavor  should  be  to  ascer- 
tain the  character  of  the  material  swallowed  and  its  point 
of  lodgment.  The  first  point  can  be  ascertained  from  the 
patient  or  friends  ;  the  second  by  an  examination  with  the 
finger,  elastic  bougie,  or  probang,  and  by  the  seat  of  the 
pain.  The  latter  symptom,  however,  is  not  reliable,  for  in 
many  instances  the  pain  remains  after  the  foreign  body  has 
been  swallowed  or  vomited.  The  patient's  statements, 
therefore,  cannot  be  implicitly  relied  on. 

In  examining  the  pharynx,  an  ordinary  laryngoscope 
may  be  used  with  advantage.  When  the  tongue  is  fully 
depressed,  and  the  light  thrown  in,  the  patient  should  then 
take  a  deep  inspiration,  which  will  separate  the  pillars  of 
the  fauces,  and  allow  inspection. 

If  the  obstruction  is  in  the  pharynx  or  upper  part  of  the 
oesophagus,  it  should  be  removed  if  possible.  If  below  the 
level  of  the  episternal  notch,  and  not  too  large  or  sharp,  it 
may  be  pushed  down  into  the  stomach.  Particles  of  food 
may  generally  be  treated  in  this  manner  when  below  the 
pomt  named,  or  when  it  is  difficult  to  extract  them.  The 
use  of  dilute  mineral  acids  will  soften  a  piece  of  bone  so  thai 
it  will  go  down  {Hall). 

Force  must  not  be  employed  in  removing  needles,  pins, 
or  other  sharp  articles,  for  fear  of  piercing,  or  lacerating  the 


94       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

mucous  membrane,  and  the  important  neighboring  parts. 
Obstructions  in  the  upper  portion  of  the  pharynx  may  be 
extracted  with  the  finger,  or  when  farther  down  with  curved 
forceps  adapted  to  the  purpose. 

Among  the  instruments  that  are  used  for  pushing  foreign 
bodies  into  the  stomach  the prohang  is  the  best.  It  consists 
of  a  thin  strip  of  wlialebone  with  a  piece  of  sponge  attached 
firmly  to  one  end.  It  is  carefully  introduced  and  moved 
slowly  downward,  until  the  foreign  body  is  reached  and  dis- 
lodged. Elastic  bougies  or  catheters  are  used  in  the  same 
manner.  When  needles  or  pins  become  impacted  in  the 
canal,  an  elastic  catheter  having  a  skein  of  silk  fastened  in 
the  eye  may  be  introduced  until  it  passes  below  the  obstruc- 
tion ;  it  is  then  drawn  up,  entangling  the  needle  or  pin  in 
the  meshes  of  the  silk  {Gi^ay).^ 

A  very  ingenious  instrument  has  recently  been  em- 
ployed by  surgeons  in  this  city^,  for  the  removal  of  foreign 
bodies.  It  consists  of  a  gum  catheter,  from  which  the  end 
has  been  cut,  a  thin  piece  of  whalebone  several  inches  longer 
than  the  catheter,  and  a  number  of  bristles.  The  whale- 
bone is  made  to  slide  readily  up  and  down  inside  the 
catheter.  Tlie  bristles  are  attached  by  an  extremity  to  the 
end  of  the  whalebone,  which  protrudes  from  the  catheter ; 
the  other  is  fastened  around  the  open  end  of  the  catheter. 
When  the  whalebone  is  pushed  out  through  the  catheter  as 
far  as  possible,  the  bristles  surround  the  whalebone  very 
closely  and  compactl3^  The  instrument  in  this  condition  ia 
then  carried  below  the  obstruction,  and  the  catheter  firmly 
held,  while  the  whalebone  is  drawn  up  within  it.  This 
causes  the  bristles  to  double  up  in  the  centre,  and  protrude 

*  Article  Foreign  Bodies,  Holmes's  Surgery,  vol.  ii.,  page  325. 


EXTRACTION  OF  FOREIGN  BODIES.  95 

all  around  in  such  a  manner,  that  when  tlie  instrument  is 
withdrawn  it  carries  the  foreign  body  witli  it. 

When  foreign  bodies  are  not  removed,  they  produce 
ulceration  and  suppuration  of  the  parts  pressed  uf)on,  and 
other  organs  become  involved.  If  milder  methods  fail,  we 
must  resort  to  oeso^hagotoiny. 

The  operation  should  be  performed  on  the  side  occupied 
by  the  foreign  body,  or,  if  this  cannot  be  determined,  the  left 
side  must  be  selected,  because,  in  the  neck,  the  oesophagus 
inclines  to  the  left  of  tlie  median  line,  and  is  therefore  more 
easily  reached. 

After  the  patient  is  fully  under  the  influence  of  an  anaes- 
thetic, the  shoulders  are  raised,  the  head  turned  to  one  side, 
and  an  incision  is  made  along  the  inner  border  of  the  sterno- 
mastoid  muscle,  commencing  on  a  level  with  the  upper 
border  of  the  thyroid  cartilage,  and  extending  down  about 
four  inches,  cutting  through  the  integument  and  platysma- 
myoides  muscle.  The  omo-hyoid  muscle  is  then  exposed, 
and  must  be  either  cut  or  pushed  aside.  The  sheath  of  the 
carotid  vessels  comes  next  in  view,  and  is  drawn  outward 
and  retained  by  an  assistant  while  the  thyroid  gland  and 
trachea  are  moved  slightly  inward.  A  bougie  is  now 
passed  down  the  throat,  and  protruded  below  so  as  to 
bring  the  oesophagus  fully  to  view  in  the  wound.  An 
opening  is  then  made,  through  which  the  foreign  body  is 
extracted. 

The  patient  should  be  fed  daily  through  a  tube  for  two 
or  three  weeks  after  the  operation,  in  order  to  give  the 
oesophageal  wound  time  to  heal. 

Foreign  Bodies  in  the  INose. — Children  of  tender  years 
are  particularly  liable  to  this  accident.     It  is  of  frequent 


9G       EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

occurrence,  but  happily  there  is  more  inconvenience  than 
danger  attending  it. 

Peas  and  beans  in  the  nasal  cavities  are  specially  trouble- 
some ;  they  enlarge  in  size  by  their  absorption  of  moisture, 
and  by  an  increase  of  pressure  cause  greater  irritation. 
Peas  and  beans  have  been  known  to  sprout  in  the  nasal 
cavities  after  having  remained  there  for  several  days,  giv- 
inrr  rise  to  serious  inflammation  of  the  mucous  membrane 
and  spongy  bones. 

Treatment. — Having  by  careful  examination  determined 
which  nostril  the  obstruction  is  in,  snuff  or  other  sternutatory 
may  be  introduced  into  the  opposite  nostril,  in  order  to  in- 
duce sneezing.  This  procedure  will  probably  dislodge  the 
foreign  body.  In  place  of  this,  a  stream  of  water,  carried 
into  the  nostril  by  means  of  "  Thudicum's  nasal  douche," 
may  wash  out  the  material.  When  simple  measures  like 
the  foregoing  are  found  useless,  the  forceps  must  be  em- 
ployed. The  long  curved  forceps  used  for  the  extraction  of 
polypi  may  be  tried.  The  instrument  is  passed  up  carefully 
to  the  foreign  body,  closed  upon  it  and  drawn  down.  In  all 
cases  care  should  be  taken  that  the  substance  is  not  forced 
back  through  the  posterior  nares  into  the  throat,  or  that  the 
efforts  at  extraction  are  not  carried  to  such  a  length  at  one 
sitting  as  to  fatigue  the  child,  or  cause  inflammation  in  the 
organ. 

FoKEiGN  Bodies  in  the  Ear. — Tlie  length  of  the  ex- 
ternal auditory  canal  is  about  one  inch  and  a  quarter,  and 
at  its  inner  extremity  is  the  merabrani  tympani,  a  delicate 
membrane  which  separates  the  middle  from  the  external 
ear.  Across  the  middle  ear  are  stretched  three  small 
bones  connected  externally  with  the  membrani  tympani, 


EXTRACTION  OF  FOREIGN  BODIES.  97 

and,  through  the  foramon  ovale,  on  the  inner  wall  with 
the  internal  ear. 

Foreign  bodies  in  the  external  ear,  in  consequence  of 
their  close  proximity  to  important  and  delicate  structures, 
may  produce  grave  and  even  fatal  results.  The  inflamma- 
tion usually  excited  by  their  pressure  may  extend  to  the  mem- 
brani  tympani,  destroying  it  and  causing  deafness.  It  may 
pass  on  to  the  middle  ear,  involving  the  temporal  bone, 
giving  rise  to  caries  and  abscess,  and  may  even  reach  the 
brain,  exciting  fatal  meningitis  or  abscess  in  the  middle 
lobe  of  the  cerebrum.  Sometimes  efforts  at  extraction  cause 
permanent  deafness  by  rupturing  the  tympanum. 

Grains  of  wheat,  corn,  seeds,  and  also  insects,  such  as 
bugs  or  fleas,  have  been  found  in  the  auditory  canal.  In- 
sects cause  great  irritation,  but  their  removal  is  not  attended 
with  difliculty.  Accumulations  of  wax  of  any  great  quan- 
tity may  cause  distress. 

If  the  body  is  large,  there  is  considerable  pain  and  singing 
in  the  ear,  and  more  or  less  deafness  is  experienced.  If  it 
is  allowed  to  remain  in  the  canal,  there  will  be  in  the  course 
of  twenty-four  to  forty- eight  hours  a  discharge  from  the 
meatus,  which  soon  becomes  purulent  and  mixed  with 
blood. 

Small  substances  do  not  excite  inflammation  so  rapidly, 
but  are  often  as  difficult  to  extract  as  large  bodies.  Insects 
create  an  itching  in  the  canal,  and  a  loud  rattling  or 
grating  noise,  excessively  annoying  to  a  nervous  individ- 
ual. 

Treatment. — Insects  are  removed  by  closing  up  the  ex- 
ternal meatus,  or  as  much  of  the  canal  as  possible,  and  pre- 
venting the  admission  of  air.     This  is  best  done  with  a 


98  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

piece  of  "  cotton- wool,"  tliorouglilj  saturated  with  a  strong 
solution  of  common  salt  or  vinegar,  and  sufficiently  largo  to 
plug  the  orifice  completely.  After  its  introduction  turn  the 
patient  on  the  affected  side,  and  allow  tlie  hand  to  press 
^^  firmly  on  the  ear.  In  a  few  minutes  the  noise  and  irrita- 
tion Avill  cease,  and,  if  the  plug  at  this  time  be  withdrawn, 
the  insect  will  probably  be  found  partially  embedded  in  its 
\  ■      substance. 

To  remove  small  bodies,  a  stream  of  water  may  be  thrown 
gently  into  the  canal,  or  a  scoop  and  bent  probe  may  be 
used.  The  scoop  should  be  introduced  into  the  upper  part 
of  the  canal,  so  that,  in  pressing  on  the  foreign  body,  the 
edge  of  the  instrument  will  recede,  instead  of  pressing 
against  the  membrani  tympani,  as  it  undoubtedly  would  if 
inserted  below.  Great  care  must  be  observed  in  the  employ- 
ment of  these  instruments,  and  very  little  force  should  be 
exerted  through  them. 

If  it  is  found  impossible  to  remove  the  obstruction  by 
these  means,  the  canal  must  be  syringed  gently  twice  each 
day  with  warm  water,  until  all  inflammatory  symptoms 
have  subsided.  In  the  majority  of  cases  the  foreign  body 
will  come  away  in  the  purulent  discharge. 

Foreign  Bodies  around  the  Eye. — Sand,  broken  eye- 
lashes, cinders,  etc.,  often  lodge  under  one  of  the  lids,  usually 
the  upper  lid.  If  these  substances  remain,  inflammation  of 
the  conjunctiva  will  be  established,  and  ulceration  set  up 
around  them. 

Treatment. — Hairs  which  have  become  fixed  in  the  con- 
junctiva should  be  extracted  with  forceps.  To  do  this,  the 
lid  is  everted,  and  the  eye  cleansed  of  any  effusion  which 
may  have  collected  around  the  hair;  the  latter  is  then  readily 


EXTRACTIOX  OF  FOREIGN  BODIES.  99 

removed.  For  the  extraction  of  dirt,  sand,  etc.,  the  follow- 
ing simple  proceeding  will  answer :  Grasp  the  upper  lid 
between  the  thumb  and  forefinger,  lift  it  from  the  eyeball 
and  draw  it  forcibly  down,  outside  of  the  lower  lid.  When 
stretched  as  far  as  possible,  allow  it  to  slide  slowly  back  to 
its  natural  position,  touching  its  fellow  as  it  goes  up,  then 
wipe  the  edges  with  a  handkerchief  so  as  to  remove  the 
foreign  body  from  the  lashes.  The  operation  can  be  repeated 
three  or  four  times,  or  oftener,  without  injury.  Some  use  a 
small  scoop  made  from  wire,  which  is  moved  around  under 
the  eyelid  from  one  canthus  to  the  other. 

Foreign  Bodies  in  the  Ueethra  and  Bladder.  —  In 
many  cases  this  occurrence  depends  on  unnatural  or  uncon- 
trolled desires  which  seek  relief  in  local  irritation  and  excite- 
ment. The  most  astounding  means  are  resorted  to  for  this 
purpose.  Slate-pencils,  hair-pins,  knitting-needles,  wire, 
pieces  of  wood,  leather  strips,  straw,  tobacco-pipes,  etc.,  are 
among  the  long  list  of  articles  which  have  been  extracted 
from  these  organs. 

Prof.  James  E..  Wood  has  in  his  collection  a  thick  leather 
thong,  with  a  large  knot  at  its  extremity,  which  a  patient 
of  his  was  in  the  habit  of  introducing  into  the  urethra. 
On  one  occasion  the  knot  passed  beyond  the  sphincter 
muscle,  and  was  forcibly  held.  It  had  to  be  removed  by 
an  operation. 

However,  there  are  other  means  by  which  foreign  bodies 
become  lodged  in  the  m*ethra  and  bladder.  In  the  dilata- 
tion of  a  stricture  with  elastic  bougies,  or  while  using  a 
catheter,  the  instrument  may  break,  and  the  pieces  remain 
impacted. 

After  remaining  a  certain  length  of  time  in  the  bladder, 


100  EMERGEXCIES,   AND   nOW   TO   TREAT   THEM. 

foreign  bodies  become  encrusted  with  various  salts,  and  grow 
larger  bv  deposit.  Sucli  an  occurrence  is  attended  with  all 
the  symptoms  and  dangers  of  stone.  In  the  urethra  they 
may  cause  inflammation  and  slougliing  of  the  mucous  mem- 
brane, and  subsequent  stricture. 

Treatment, — Extraction  is  necessary  in  all  cases.  "When 
impacted  in  the  male  urethra,  the  removal  may  be  effected 
by  a  forceps  adapted  to  the  canal.  If  this  fail,  urethrotomy 
must  be  performed.  Foreign  bodies  in  the  male  bladder 
are  sometimes  broken  up  with  a  lithotrite;  but  in  most 
cases  perineal  section  {see  page  61),  or  some  of  the  opera- 
tions for  stone,  are  usually  made.  Substances  may  be  taken 
from  the  female  bladder  with  a  forceps.  The  urethra  in 
females  is  very  short  and  easily  dilated,  so  that  the  introduc- 
tion of  a  forceps  or  other  instrument  is  accomplished  with- 
out difficulty. 

FoEEiGX  Bodies  ix  the  Eectum  is  a  rare  accident.  Fall- 
ing on  the  rung  of  a  chair,  or  on  fence-spokes,  may  result  in 
a  portion  of  these  materials  entering  the  rectum.  The  prin- 
cipal danger  is  from  laceration  of  the  bowel,  uterus,  or 
bladder.     Death  usually  follows  rupture  of  the  latter  organ. 

The  treatment  consists  in  keej)ing  the  bowels  quiet, 
relieving  pain  by  opiates  and  warm  fomentations  to  the 
abdomen  and  anus.  If  the  mucous  membrane  is  torn  to 
any  extent,  and  the  injury  will  admit  of  it,  the  parts  maybe 
drawn  too-ether  with  sutures. 


CHAPTER  YIII. 


BUB  If  8    AND    SCALDS. 


f  arieties  of  Deformities  produced  by  Burns. — Spontaneous  Combustion. — Clas- 
sification of  Burns. — Constitutional  Symptoms. — ^Duodenal  Ulcers. — Causes 
of  Death,  etc.— Effects  of  Cold.— Frost-Bite. 

Theee  are  few  accidents  whicli  combine  so  many  tin- 
natural  elements  as  burns  and  scalds.  In  none  do  we  wit- 
ness so  much  agony  or  such  poor  results  from  treatment. 

Burns  are  to  be  dreaded  in  their  remote  results,  as  well 
as  in  their  immediate  consequences.  Recovery  in  many 
cases  is  accompanied  by  hideous  deformity.  Severe  facial 
burns  not  unfrequently  leave  the  face  twisted  and  distorted 
to  such  a  degree  as  to  almost  destroy  its  semblance  to 
humanity.  The  cheeks  may  be  stretched  to  one  side,  the 
angles  of  the  mouth  widely  separated,  or  the  lower  jaw 
drawn  toward  the  shoulder,  by  a  cicatrice  of  the  neck.  Burns 
of  the  neck  may  bend  the  head  sideways,  or  draw  it  down 
on  the  chest.  Where  the  arms  or  hands  are  burned,  the 
cicatrices  bend  the  joints  out  of  place,  and  impair  their 
movements.  Thus  the  fingers  may  be  doubled  up  and 
clinched,  or  the  forearm  flexed  or  strongly  pronated.  Some- 
times the  eyelids  are  fastened  to  the  cheek,  or  drawn  upward 
on  the  forehead.  In  the  latter  case  the  eyeballs  cannot  be 
covered  or  protected  from  irritating  particles  of  dust ;  great 
distress  results  in  this  condition,  from  want  of  sleep.    A  case 


102  EMERGENCIES,   AND   HOW  TO   TREAT   THEM. 

of  this  kind  came  under  my  care  at  Bellevue,  in  a  female 
patient  ■who  suffered  from  a  severe  burn  of  the  forehead  and 
arm.  The  upper  eyelid  was  drawn  up  on  the  forehead,  and 
fastened  above  the  superciliary  ridge.  The  suffering  for 
waut  of  sleep  was  considerable.  Even  opiates  failed  to 
bring  relief.  Ordinary  covering  for  the  eye  only  produced 
irritation.  Finally,  as  there  was  no  integument  near  from 
which  to  manufacture  a  new  lid,  I  dissected  the  old  one  from 
its  attachment  on  the  forehead,  and  drew  it  down.  It  was 
retained  in  its  position,  until  the  healing  process  became 
complete,  by  means  of  a  fine  silver  wire  passed  through,  near 
the  free  margin  of  the  lid,  carried  down  across  the  end  of 
the  nose,  and  fastened  at  the  back  part  of  the  head  to  the 
other  end  of  the  wire  from  the  opposite  side.  This  unusual 
operation  answered  the  purpose  admirably.  Being  retained 
in  its  position  for  several  weeks,  the  cicatrice  was  prevented 
from  contracting  so  as  to  uncover  the  eye,  and  leave  it  with- 
out protection.  Sleep  was  procured  for  the  patient ;  most 
of  the  hideous  deformity  removed,  and  the  old  lid  performed 
its  duty  once  more. 

Many  cases  of  burning  arise  from  carelessness  in  the 
use  of  kerosene  and  other  explosive  oils  in  tenement-houses. 
This  class  of  burns  has  attained  a  magnitude,  in  point  of 
numbers,  which  is  truly  alarming.  The  columns  of  our  morn- 
ing journals  are  seldom  without  the  history  of  a  victim. 
These  accidents  usually  arise  from  filling  lamps  near  alight, 
or  from  pouring  kerosene  on  kindling-wood  to  make  a 
brighter  flame.  Sometimes  they  are  occasioned  by  careless- 
ness in  shutting  off  gas.  The  material  escapes  until  the 
apartment  is  filled,  and  upon  the  entrance  of  a  person  with 
a  light  an  explosion  takes  place,  and  frightful  burns  result. 


BURNS  AND  SCALDS.  103 

Recovery  from  sucli  burns  is  rare,  owing  to  tlic  extent  of 
surface  injured. 

Dangerous  burns  are  also  produced  by  tlic  contact  of 
melted  metals  with  the  body.  They  burrow  into  the  flesh, 
and  cause  great  destruction  of  tissue,  and  fearful  scars. 
Melted  sugar,  hot  mash,  boiling  water,  etc.,  when  applied 
to  the  body,  are  not  characterized  by  the  same  deep  eschars 
which  attend  scalds  with  other  substances.  Their  effect  is 
superficial,  but,  as  they  sometimes  extend  over  a  greater  sur- 
face of  the  body,  they  are  usually  as  fatal  as  burns  from  flame. 

The  appalling  phenomena  of  spontaneous  combustion 
may  be  mentioned  in  this  connection.  Several  cases  of  it 
are  recorded,  by  reliable  observers.  It  takes  place  in  persons 
who  imbibe  the  worst  varieties  of  ardent  spirits.  There  is 
much  diversity  of  opinion  respecting  this  curious  accident. 
Some  hold  that  the  system  becomes  so  thoroughly  impreg- 
nated with  alcohol  as  to  make  ignition  possible  through  the 
medium  of  the  breath  ;  or,  that  combustible  gases  are  gen- 
erated internally,  which  take  fire  and  destroy  independently 
of  external  influences.  The  majority  of  investigators,  how- 
ever, believe  that  the  combustion  commences  on  the  outside 
of  the  body.  Thus,  a  person  completely  stupefied  from 
alcohol  may  fall  or  lie  down  in  the  vicinity  of  a  fire,  and  the 
flame  may  be  communicated  to  his  clothing.  His  helpless- 
ness, and  the  body  being  loaded  with  fat  and  alcohol,  fur- 
nish all  the  materials  for  rapid  combustion,  and  the  un- 
fortunate creature  soon  becomes  a  blackened,  fetid  mass. 

In  ordinary  burns  the  danger  to  life  varies  with  the  seat 
and  extent  of  the  tissue  destroyed.  Burns  of  the  thoracic 
or  abdominal  walls  are  attended  with  the  greatest  danger, 
on  account  of  the  proximity  of  important  viscera. 


104r  EMERGENCIES,   AND   DOW   TO   TREAT   THEM. 

A  superficial  burn,  involving  a  large  integuniental  area, 
is  apt  to  prove  fatal.  Localized  deep  escliars  arc  not  par- 
ticularly serious,  unless  important  nerves  or  vessels  are 
destroyed. 

When  tlie  air-passages,  pharynx,  or  oesophagus,  are  in- 
jured from  hot  liquids  or  steam,  the  prognosis  is  always 
bad. 

The  mortality  from  burns  is  always  greater  in  childhood 
than  in  adults.  The  delicate  and  susceptible  nervous  sys- 
tem of  the  child  succumbs  to  a  burn,  which  would,  compar- 
atively, be  of  little  consequence  to  an  adult.  In  persona 
of  tender  years  these  accidents  usually  terminate  in  convul- 
sions. 

Dupuytren  divides  burns  into  six  classes.  Other 
surgeons  have  increased  the  number.  For  our  present 
purposes  four  degrees  of  burns  will  be  sufficient :  The  first 
includes  all  burns  which  redden  the  cutis  and  produce  slight 
vesication.  The  second  includes  all  cases  where  the  true 
skin  is  either  partially  or  completely  destroyed,  and  bullae  or 
eschars  of  a  brown  color  result.  The  third  class  includes 
all  which  extend  through  the  subcutaneous  cellular  tissue 
into  the  muscular  substance.  The  fourth  includes  those  in 
which  all  the  tissues  of  a  limb  are  more  or  less  involved  in 
the  destructive  process. 

"We  usually  find,  in  burns,  the  first  two  degrees  combined 
in  the  part  affected.  Where  boiling  water  is  spilled  on  the 
surface,  the  tissue  is  not  broken  up  as  when  flame  is  ap- 
parent ;  with  the  worst  cases  the  true  skin  is  merely  deprived 
of  its  cutis  and  reddened.  Our  classification,  therefore,  does 
not  apply  to  this  variety. 

The  immediate  symptoms  accompanying  severe  burns 


BURNS  AND  SCALDS.  105 

may  be  divided  into  three  stages,  each  differing  in  a  marked 
degree,  and  giving  rise  to  different  indications  for  treatment. 
The  immediate  symptoms  accompanying  the  first  stage  of 
severe  burns  are  those  of  collapse.  The  pulse  is  small  and 
feeble.  The  extremities  are  cold  and  clammy.  There  are 
great  thirst,  with  difficulty  in  swallowing  {dysphagia)^  and 
nausea  and  vomiting.  The  patient's  countenance  is  shrunk- 
en, and  has  an  expression  of  anxiety.  Chills  and  rigors 
are  present.  The  most  prominent  symptom  is  the  intense 
agonizing  pain.  The  pain  is  probably  more  acute  than  in 
any  other  form  of  injury,  and  oftentimes  only  relieved  by 
death.  This  stage  lasts  from  twenty-four  to  forty-eight 
hours,  and  the  greatest  number  of  fatal  cases  occur  in  it. 

A  post-mortem  examination  of  persons  who  die  in  the 
first  stage  reveals  great  congestion  of  the  brain  and  its  mem- 
branes, serous  effusion  into  the  ventricles,  and  on  the  surface 
of  brain.  There  is  also  marked  congestion  of  all  the  inter- 
nal organs. 

The  second  stage  or  period  of  reaction  is  recognized  by 
an  increase  in  the  temperature  of  the  body,  and  a  rapid 
pulse.  The  skin  feels  hot  to  the  touch,  and  the  tongue  is 
brown  and  dry ;  the  dryness  being  particularly  apparent  in 
the  centre.  There  is  intense  pain  in  the  head  {cephalalgia)^ 
and  sometimes  delirium.  Yomiting  may  also  be  present  in 
this  stage.  The  dangers  in  the  second  stage  arise  from 
inflammatory  affections  of  different  viscera.  "Meningitis  is 
liable  to  occur.  Pneumonia  or  bronchitis  stands  next  in 
order  of  frequency.  Inflammation  of  the  intestines,  giving 
rise  to  ulceration,  is  not  uncommon.  The  inflammation 
usually  commences  in  the  upper  portion  of  the  small  in- 
testines.    The  peculiar  duodenal  ulcer  which  accompanies 


106      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

severe  burns  may  take  place  in  this  period,  although  it  ia 
more  freqncntlv  seen  in  the  third.  This  ulcer  is  situated 
at  the  upper  portion  of  the  duodenum  near  the  pylorus. 
Bowman  supposes  it  to  be  caused  by  the  extra  labor  thrown 
on  the  intestinal  glands  in  consequence  of  suppressed  cu- 
taneous secretion.  It  is  recognized  by  pain  in  the  right 
hypochondrium,  loose  and  sometimes  bloody  evacuations 
from  the  bowels.  Usually  it  appears  on  the  tenth  day, 
but  it  may  commence  as  early  as  the  fourth. 

The  duration  of  this  stage  varies  from  one  to  two  weeks. 
The  2)ost-mo?'te?7i  appearances  are  principally  those  belong- 
ing to  different  inflammations.  If  meningitis  have  super- 
vened, the  arachnoid  will  be  found  opaque,  and  studded 
with  flakes  or  patches  of  lymph.  The  membrane  is  raised 
by  effusion  of  serum  into  the  meshes  of  the  pia  mater.  The 
brain  is  congested,  and  the  ventricles  contain  serum.  The 
lungs  may  present  various  stages  of  pneumonia,  or  be 
simply  engorged.  There  is  congestion  throughout  the  in- 
testinal canal,  but  especially  in  the  duodenum,  and  there 
may  be  ulceration. 

A  diminution  in  the  febrile  symptoms,  and  the  com- 
mencement of  suppuration,  usher  in  the  third  stage.  In 
severe  cases,  the  patient's  condition  is  similar  to  that  of  the 
first  stage.  If  the  suppuration  be  excessive,  death  soon  en- 
sues from  exhaustion.  The  pathological  changes  are  much 
the  same  as  in  the  preceding  stage,  with  the  exception  that 
the  brain  and  its  membranes  are  not  so  often  the  seat  of 
inflammatory  changes,  and  ulcers  are  more  frequently 
found. 

The  most  common  causes  of  death  in  each  period  are,  in 
the  first  stage,  collapse  from  injury  to  the  nervous  system 


BURNS  AND  SCALDS.  107 

and  coma  due  to  cerebral  congestion.  Second  staj^e,  in- 
flammatory  disorders,  as  meningitis,  pneumonia,  peritonitis, 
etc.  Third  stage,  exhaustion  from  excessive  suppuration, 
hasmorrhage,  or  peritonitis  from  perforation  of  an  ulcer,  and 
thoracic  inflammation. 

The  constitutional  treatment  varies  in  each  period.  In 
the  first  stage  the  intolerable  pain  should  be  relieved  by 
opiates,  and  the  patient  roused  from  his  prostration  and 
collapse  by  the  free  use  of  stimulants.  And  it  must  be 
borne  in  mind  that,  when  excessive  pain  exists,  the  system 
can  bear  double  doses  of  narcotic  medicines.  Two  or  three 
grains  of  opium  may  be  given  to  adults  at  short  intervals, 
and  increased  if  necessary.  Morphia  is  best  administered 
in  solution,  and,  of  the  two  liquid  preparations  employed, 
Magendie's  is  the  best.  From  twenty  to  thirty  drops  may 
be  given  by  the  mouth,  or  by  hypodermic  injection.  If  the 
preparations  of  opium  fail,  hydrate  of  chloral  in  half- 
drachm  doses,  or  anaesthetic  inhalations,  may  be  tried.  Do 
not  let  the  unfortunate  patient  suffer,  but  relieve  him  at  all 
hazards. 

In  conjunction  with  narcotics,  brandy  may  be  given  by 
mouth  or  rectum.  Hot  bottles  applied  to  the  extremities 
will  be  found  of  service.  As  soon  as  heat  of  the  skin  and 
increased  frequency  of  the  pulse  indicate  reaction,  diminish 
the  quantity  of  stimulants. 

In  the  second  stage  there  is  an  entire  change  in  the  con- 
dition of  the  patient.  Inflammation  is  present  in  some  of 
the  viscera.  The  treatment  will  of  course  vary  with  the 
organ  involved.  Should  the  pain  continue,  opiates  must  be 
administered.  Stimulants  may  be  kept  up  and  their  action 
carefully  watched.      Antiphlogistic  measures   are  not  re* 


i08      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

quired.  Beef-tea,  broths,  and  other  light,  nourishing  diet, 
are  always  beneficial,  and  cannot  be  dispensed  with. 

In  the  third  stage  there  is  great  exhaustion,  and  efforts 
must  be  made  to  sustain  the  rapidly-failing  vitality  of  the 
patient.  Brandy,  with  or  without  ammonia,  should  be  ad- 
ministered freely  in  conjunction  with  quinine.  This  valu- 
able drug  may  always  be  employed  in  the  treatment.  Five 
grains  every  three  or  four  hours  will  be  sufficient.  Beef- 
tea,  raw-scraped  beef,  eggs,  oysters,  and  other  nutritious 
articles,  are  also  essential.  They  may  be  given  in  all  cases. 
If  the  stomach  be  too  irritable  to  receive  the  medicine,  diet, 
or  stimulants,  they  can  bo  safely  given  by  injection. 

There  are  three  important  rules  to  be  remembered  in  the 
local  treatment  of  burns  :  1.  Exclude  atmospheric  air.  2. 
Only  remove  the  dressings  when  they  become  loosened  by 
the  discharges.     3.  Prevent  the  contraction  of  cicatrices. 

In  simple  burns  which  do  not  involve  the  true  skin,  very 
little  treatment  is  necessary.  The  part  may  be  kept  wet  by 
cloths  dipped  in  water  or  sweet-oil.  "When  the  true  skin  is 
partially  or  completely  destroyed,  a  thick  layer  of  flour 
may  be  placed  over  the  burned  surface,  and  covered  by 
cotton.  Lint  or  cotton,  dipped  in  a  mixture  consisting  of 
equal  parts  of  linseed-oil  and  lime-water  (carroTv-oil),  can  be 
used  instead  of  the  flour.  Some  envelop  the  burnt  part 
in  cotton  saturated  with  sweet-oil  alone,  and  others  apply  a 
solution  of  nitrate  of  silver  first,  then  cover  the  lint  with 
cotton.  I  have  seen  the  best  results  from  the  employment 
of  flour  and  carron-oil^  and  prefer  them  over  all  others. 
Whatever  dressing  is  employed,  it  should  not  be  disturbed 
until  separated  by  the  exudation  underneath,  or  unless  foul 
odors  arise.     In  changing,  every  particle  should  be  carefully 


BURNS  AND  SCALDS.— EFFECTS  OF  COLD.  109 

removed,  and  the  parts  thoroughly  washed  witli  some  dis- 
infectant liquid,  such  as 

5.   Acidi  carbolici 3j. 

Aqu£B fl.  §  viij.  M. 

This  solution  may  also  be  sprinkled  on  the  dressings  and 
bedclothes. 

"When  granulations  grow  above  the  surface,  the  sore  will 
not  heal;  applications  of  nitrate  of  silver  and  strapping  with 
adhesive  plaster  will  then  be  required. 

During  cicatrization,  the  great  tendency  to  contraction 
and  deformity  must  be  counteracted  by  splints  or  band- 
ages, and  parts  supported  in  their  normal  position  until 
the  healing  process  is  completed.  The  hideous  deformi- 
ties which  arise  from  the  contractions  of  cicatrices  are 
sometimes  remedied  by  surgical  procedures.  ISTo  special 
rules  can  be  laid  down  for  those  operations,  as  each  one  has 
its  own  separate  requirements,  and  the  common-sense  of  the 
surgeon  must  alone  be  the  guide. 

EFFECTS   OF   COLD. — FKOST-BITES. 

Cold  is  a  valuable  therapeutical  agent  in  many  diseases. 
Cold  shower-baths  or  ordinary  cold-water  baths  have  a  stim- 
ulating effect  on  the  system,  invigorating  both  the  mental 
and  physical  forces.  A  dry  cold  atmosphere  is  also  an 
efficient  agent  in  maintaining  the  vital  powers  at  a  normal 
standard,  and  in  destroying  or  keeping  in  abeyance  inju- 
rious miasm. 

Exposure  of  the  body  to  intense  cold  results  in  a  local 
or  general  loss  of  vitality.  It  produces  a  feeling  of  depres- 
Bion,  a  disturbance  of  the  mental  faculties,  and  a  great 
desire  to  sleep,  which,  if  indulged  in,  soon  increases  until  a 


110  EMERGENCIES,   AND   UOW   TO   TREAT   THEM. 

state  of  profound  coma  is  reached  wliich  may  end  in  death. 
The  desire  to  sleep  is  beyond  the  control  of  the  suft'erer,  and 
it  is  here  that  the  great  danger  lies.  If  the  power  of  re- 
sistance, or  an  appreciation  of  the  danger  were  felt,  the 
person  exposed  might  be  enabled  to  resist  until  assistance 
was  obtained.  TVhen  the  coma  is  developed,  it  is  almost 
impossible  to  arouse  the  patient. 

The  comatose  condition  is  brought  about  by  congestion 
of  the  brain.  The  intense  cold  propels  the  blood  from  the 
surface  to  the  internal  organs.  The  functions  of  the  brain, 
in  common  with  those  of  other  organs,  are  interfered  with 
by  the  pressure  of  the  accumulated  blood,  and  insensi- 
bility supervenes.  It  is  also  probable  that  an  accumulation 
of  carbonic  acid  takes  place  in  the  blood  owing  to  the 
diminished  respiratory  movements,  and  through  its  narcotic 
eifect  assists  in-  producing  the  coma.  Fatigue  and  intem- 
perance are  two  great  auxiliaries  in  making  the  system  sus- 
ceptible to  the  effects  of  cold.  Persons  who  have  been 
overworked,  or  wdio  have  imbibed  freely  of  alcoholic  bev- 
erages, succumb  readily  to  cold.  Temperate  men  resist  long 
exposure  to  a  low  temperature. 

The  condition  of  the  atmosphere  modifies  the  effect 
of  cold.  Thus  a  much  lower  temperature  can  be  borne 
when  the  atmosphere  is  still  than  when  the  wind  is  blowing. 
"When  a  breeze  exists,  the  warm  stratum  of  air  nearest  the 
body  is  removed  rapidly,  and  cold  air  takes  its  place ;  there 
is  consequently  more  heat  abstracted  from  the  body  than  in 
the  former  condition.  Air  is  a  bad  conductor  of  heat,  and 
these  warm  strata  afford  a  certain  amount  ot  protection, 
and  lessen  the  demand  for  a  higher  temperature. 

When  only  a  portion  of  the  body  is  exposed  to  the  cold, 


FROST-BITES.  HI 

as  the  eyes,  ears,  nose,  etc.,  there  is  a  h^cal  loss  of  vitality. 
The  part  becomes  pale  and  bloodless,  and  is  devoid  of  sen- 
sation. If  the  vitality  is  only  partially  destroyed,  a  condi- 
tion arises  which  is  known  as  frost-bite  ;  where  the  exposure 
has  been  long  continued,  and  the  life  of  the  part  totally  de- 
stroyed, gangrene  rapidly  ensues.  Little  or  no  pain  is  ex- 
perienced until  recovery  begins,  and  the  circulation  is 
renewed.  The  pain  is  intense,  and  always  the  forerunner 
of  more  or  less  inflammation.  The  parts  become  red, 
swollen,  and  hot,  and  the  cuticle  peels  off.  Resolution  may 
occur  in  a  day  or  two,  or  the  inflammation  may  continue 
nntil  sloughing  or  gangrene  takes  place. 

Extreme  degrees  of  cold  and  heat  have  analogous  effects. 
In  both  the  vitality  is  destroyed,  and  in  both  there  are  subse- 
quent inflammation  and  sloughing  of  tissue,  with  constitu- 
tional disturbance. 

Treatment. — A  person  suffering  from  frost-bite  should 
be  placed  in  a  cold  room.  The  part  frozen  may  then  be 
rubbed  with  snow,  or  ice-water  poured  on  it,  until  sensation 
begins  to  return.  The  occurrence  of  stinging  pain,  with  a 
change  in  color,  is  a  signal  to  stop  all  rubbing  or  other 
measure  which  might  excite  inflammation.  Cloths  wet  with 
ice-water  may  then  be  applied  to  the  part.  If  the  inflam- 
mation extend  to  the  deeper  tissues  and  suppuration  occur, 
the  cloths  can  be  wet  in  a  solution  of  carbolic  acid  and  ice- 
water,  and  the  application  continued.  When  gangrene  sets 
in,  amputation  is  generally  necessary. 

In  cases  where  the  constitutional  effects  of  cold  call  for 
treatment,  general  stimulation  is  necessary.  Brandy  and 
ammonia  are  to  be  given  internally,  while  the  body  should 
be  briskly  rubbed  with  the  hands  and  warm  flannel. 


CHAPTER  IX. 

STRANGULATED    HERNIA. 

Oauscs  and  Symptoms  of  Strangulation. — Ileus. — Volvulus. — Taxis. — Operations 
for  Inguinal  and  Femoral  Ilerniaj. 

The  escape  of  anj  viscus  from  its  natural  cavity  is  called 
a  hernia.  The  term  is  in  a  measure  restricted  to  the  pro- 
trusion of  a  portion  of  intestine  or  omentum  from  the  ab- 
dominal cavity.  The  affection  is  of  common  occurrence. 
In  ordinary  cases  it  is  attended  with  little  inconvenience 
or  danger.  If,  however,  a  constriction  takes  place  at  the 
neck  of  the  hernial  sac,  which  cuts  off  tlie  circulation  of 
blood,  and  obstructs  the  passage  of  fecal  matter  through 
the  intestines,  the  patient's  life  is  at  once  in  jeopardy.  The 
portion  of  intestines  so  constricted  is  termed  a  strangulated 
hernia. 

Hernial  protrusions  usually  occur  at  the  inguinal  or 
crural  canals ;  but  they  may  pass  through  the  umbilicus, 
or  other  part  of  the  abdominal  walls. 

A  hernia  may  become  strangulated:  1.  From  the  addi- 
tional protrusion  of  intestines  or  omentum  into  the  sac 
during  the  act  of  straining,  or  other  violent  exertions  which 
bring  the  abdominal  muscles  into  violent  action. 

2.  Thickening  of  the  sac  or  its  contents  by  cell-pro- 
liferation, or  deposit  of  adipose  tissue. 


STRANGULATED  HERNIA.  II3 

3.  Contraction  of  bands  of-  fibrine  over  the  neck  of  the 
6ac. 

4.  Spasmodic  contraction  of  the  muscular  fibres  at  the 
same  point. 

6.  Contraction  of  the  ring,  from  growth  of  new  tissue. 

All  of  these  causes  may  combine  to  induce  strangulation. 
In  inguinal  hernia  the  constriction  is  usually  situated  at 
the  internal  or  external  abdominal  rings.  In  femoral  hernia 
it  may  be  at  the  crural  ring,  or  the  saphenous  opening. 

The  strangulation  is  first  manifested  by  pain  over  the 
hernial  tumor.  The  pain  increases  in  intensity,  and  rapidly 
spreads  to  other  portions  of  the  abdomen.  Soon  there  are 
nausea  and  vomiting.  The  vomited  materials  consist  first 
of  the  contents  of  the  stomach,  and  then  of  stercoraceous 
matter.  The  bowels  are  obstinately  constipated.  Cathar- 
tics fail  to  influence  them.  The  pulse  is  rapid,  increasing  in 
feebleness  as  the  strangulation  continues.  The  abdomen 
is  tympanitic,  and  pressure  at  any  part  is  attended  with 
great  pain.  This  indicates  the  extension  of  the  peritoneal 
inflammation.  Finally,  the  extremities  beconle  cold  and 
clammy,  and  the  pulse  can  scarcely  be  distinguished  at  the 
wrist.  All  the  signs  of  collapse  are  present,  and  death 
rapidly  ensues  unless  the  strangulation  be  relieved.  When 
collapse  sets  in,  operative  measures  are  of  little  avail. 

In  all  cases  where  a  patient  is  vomiting,  and  complain- 
ing of  pain  in  the  abdomen,  an  examination  should  be  in- 
stituted for  hernia.  Fatal  mistakes  are  made  by  neglecting 
this  precaution,  and  the  sick  person  treated  for  colic  and 
indigestion.  At  the  same  time  it  is  well  to  avoid  the  other 
extreme,  and  take  care  not  to  cut  into  an  inflamed  bubo,  or 
an  inflamed  incarcerated  hernia,  on  the  supposition  that 


il4      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

strangulation  exists.  These  things  arc  occasionally  done 
even  by  men  of  standing.  If  obstinate  constipation  and 
vomiting  of  fecal  matter  exist,  there  is  little  room  for  mis- 
take; neither  of  these  will  be  connected  with  a  bubo  or  in- 
flamed hernial  sac. 

The  intestines  may  be  constricted  without  leaving  the 
abdominal  cavity.  Portions  of  the  colon  may  twist  upon 
themselves  {ileus),  in  such  a  manner  as  to  cut  off  the  circu- 
lation. The  twisting  is  usually  found  at  the  sigmoid  flexure. 
It  is  recognized  as  a  prominent  tympanitic  tumor  over 
the  part  affected,  and  by  accompanying  signs  of  strangula- 
tion. 

A  portion  of  intestine  may  become  invaginated  or  in- 
verted {volvulus),  like  the  finger  of  a  glove  doubled  in,  and 
occasion  all  the  symptoms  and  danger  of  strangulation. 
Volvulus  may  occur  at  any  age,  but  it  is  most  common  in 
childhood.  It  occurs  suddenly,  with  pain  located  at  the  point 
of  constriction.  In  addition  to  the  ordinary  signs  of  strangu- 
lation, there  are  frequent  desire  to  go  to  stool,  and  discharges 
of  blood  and  mucus  from  the  bowels.  The  invaginated 
part  may  slough  off — the  two  ends  of  the  intestines  unite, 
and  the  patient  recover.  If  allowed  to  remain  until  slough- 
ing occurs,  a  favorable  termination  is  not  likely  to  ensue. 

Treatment. — The  injection  of  air  or  fluids  into  the  in- 
testines is  highly  recommended  in  volvulus.  The  injected 
material,  by  distending  the  gut,  forces  up  the  invaginated 
part.  Some  recommend  cutting  down  upon  the  intestines 
at  the  part  where  the  pain  exists,  and  drawing  out  the  in- 
verted intestine.  A  similar  course  may  be  adopted  in  the 
treatment  of  ileus. 

In  ordinary  strangulated  hernia,  efforts  should  be  made 


STRANGULATED  HERNIA.  115 

to  reduce  it  by  manipulation  [taxis).  The  muscles  are  first 
relaxed  by  opium,  hot  baths,  or  anaesthetics.  The  thigh  is 
then  partially  flexed  and  adducted,  and  the  body  of  the  pa- 
tient raised  in  bed.  Firm  pressure  is  then  made  witli  tlie 
right  hand  on  the  tumor,  while  the  left  is  placed  at  the  neck 
of  the  sac,  to  keep  it  from  bending  or  doubling  upon  itself 
in  the  reduction.  Taxis  must  not  be  kept  up  too  long,  or 
performed  with  violence.  Great  pressure  may  force  the 
hernia,  constriction  and  all,  back  into  the  peritoneal  cavity. 
Such  an  accident  complicates  matters.  Should  the  ma- 
nipulations be  without  avail,  the  constriction  must  be  re- 
moved at  once  by  an  operation.  The  patient  is  first  put 
under  the  influence  of  an  ansesthetic.  If  the  hernia  be  of 
the  oblique,  inguinal  variety,  an  incision  is  made  through 
the  integument  in  the  long  diameter  of  the  sac.  The  suc- 
ceeding layers  are  opened  on  a  director.  They  are  in 
order  from  without,  inward — two  layers  of  superficial  fascia, 
intercolumnar  fascia,  cremaster  muscle,  infundibuliform 
fascia,  subserous  areolar  tissue,  and  peritonaeum.  When  the 
tissues  are  thickened,  a  greater  number  of  layers  may  be 
made  by  splitting  up  the  fascia  with  the  director.  These 
layers  are  not  always  recognizable.  Some  surgeons  repudi- 
ate them  altogether,  and  rely  upon  the  appearance  of  the 
sac  or  its  contents  as  a  guide.  The  peritonaeum  is  recog- 
nized (provided  it  is  not  thickened  by  inflammation)  by  its 
tension,  and  the  arborescent  arrangement  of  its  blood-ves- 
sels." If  the  peritonaeum  cannot  be  recognized  before,  it 
maybe  after  it  is  cut  through,  by  the  escape  of  dark-colored 
serum,  which  generally  exists  inside  the  sac.  The  intes- 
tines are  known  by  their  dark  color  and  polished  surface. 
When  the  intestine  is  exposed,  the  little-finger  of  the  left 


116  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

baud  is  passed  up  to  tlie  part  of  stricture  wLicli  can  Le  felt 
like  a  "  hard,  bony  ring  "  at  the  neck  of  the  sac.  A  hernia- 
knife,  or  an  ordinary  bistoury,  with  its  point  protected  by 
adhesive  plaster,  is  tlien  introduced  on  its  flat  surface,  be- 
tween the  nail  of  the  littl6  finger  and  the  constriction. 
When  it  has  passed  under,  the  edge  of  the  blade  is  turned 
up,  and  the  stricture  cut  directly  upward.  By  cutting  in 
this  direction,  the  epigastric  artery,  ■which  runs  up  between 
the  two  rings,  is  avoided. 

If  the  intestine  is  in  a  fit  condition  to  return  to  the  ab- 
domen, it  will  change  color  soon  after  the  stricture  is  re- 
lieved. In  this  case  it  is  returned  slowly — the  part  which 
came  out  last  being  replaced  first.  Should  gangrene  have 
set  in,  there  will  be  a  fetid  odor,  the  intestine  will  be  of  a 
dark-gray  color,  and  ma}"  crepitate  on  pressure,  from  the 
presence  of  putrefactive  gases  in  the  walls.  The  gangre- 
nous portion  is  to  be  removed,  and  an  artificial  anus  made 
by  sewing  the  cut  ends  to  the  edge  of  the  opening. 

In  direct  inguinal  hernia,  the  layers  are  somewhat  dif- 
ferent, but  the  operation  is  precisely  similar.  Instead  of 
the  cremaster  muscle,  the  conjoined  tendon  of  the  internal, 
oblique,  and  transversalis  muscles  is  substituted,  and  the  in- 
fundibuliform  fascia  is  replaced  by  the  fascia  transversalis. 

In  operating  for  femoral  hernia,  a  crucial  or  a  T-shaped 
incision  is  made — the  first  one  in  the  long  diameter  of  the 
sac,  parallel  with  Poupart's  ligament,  and  the  second  meet- 
ing the  first  at  right  angles.  The  layers  to  be  divided  are : 
The  integument,  superficial  fascia,  cribriform  fascin,  crural 
sheath,  septum  crurale,  subserous  areolar  tissue,  and  perito- 
nseum.  The  stricture  is  divided  by  cutting  upward  and  in- 
ward.    In   order  to    avoid   cutting  the   obturator  artery, 


STRANGULATED  HERNIA,  117 

which  occasionally  runs  along  the  inner  edge  of  Gimbemat's 
ligament — the  edge  of  the  knife  may  be  blunted  prior  to  the 
operation.  When  this  is  done,  the  artery  -will  be  pushed 
before  the  knife,  instead  of  being  wounded. 

Taxis  is  employed  in  femoral  hernia,  by  first  flexing  the 
thigh,  rotating  it  inward,  and  pressing  the  protrusion  down- 
ward, backward,  and  then  upward. 


CHAPTER  X. 

loss    OF  CO^^'SCIOUS^£SS. 

COMA. 

Coma  from  Compression  of  tLo  Brain  —  Embolism  —  Urasmia  —  Alcohol, 
Hysteria — Epilepsy. — Concussion. 

A  susPExsiox  of  cerebral  activity  and  uncoDsciousnesa 
is  the  common  sequence  of  many  abnormal  clianges.  It 
may  result  from  structural  lesions  in  the  brain,  or  from  the 
effects  of  poisonous  substances  carried  to  that  organ  by  the 
blood.  It  may  arise  from  a  deficient  supply  of  healthy 
blood  to  tlie  nerve-tissue,  as  in  syncope,  or  from  defective 
aeration  of  the  blood,  as  in  asphyxia. 

Coma  which  arises  from  cerebral  lesions,  or  from  the 
circulation  of  urea  or  alcohol  in  the  blood,  will  be  consid- 
ered in  this  chapter. 

By  the  term  coma  we  mean  a  state  of  j)artial  or  com- 
plete insensibility — a  suspension  of  the  ordinary  powers  of 
sensation  and  volition,  accompanied  by  stertorous  breath- 
ing. As  this  condition  is  merely  a  representative  of  diverse 
disorders,  a  just  appreciation  of  the  cause  of  each  variety 
is  essential  to  effective  treatment. 

The  causes  of  coma  are:  1.  Pressure  on  the  brain- 
substance,  from  extravasated  blood,  depressed  fracture  of 


LOSS  OF  CONSCIOUSNESS.  II9 

cranial  bones,  and  inflammatory  products ;  2.  Anaemia  of 
the  brain,  as  in  embolism  and  thrombosis;  3.  Blood-poi- 
sons, as  urea,  alcohol,  etc. ;  4.  Epilepsy ;  5.  Hysteria. 

Extravasation  of  blood  on  the  surface  of  the  brain  is 
usually  the  result  of  external  violence.  When  it  occurs  in 
the  substance  of  that  organ,  it  proceeds  from  a  diseased 
condition  of  the  cerebral  blood-vessels.  They  may  be 
affected  by  simple  fatty  or  atheromatous  degeneration. 
Accordiug  to  Yirchow,  the  latter  commences  as  a  low  grade 
of  inflammation  in  the  lining  membrane  of  the  artery 
There  is  a  slight  exudation  between  the  inner  and  middle 
coats,  and  subsequent  softening  and  breaking  down  of  the 
different  layers.  In  the  debris  of  disintegrated  tissue  we 
And  fat,  cholesterine,  calcareous  salts,  and  albumen.  If 
there  is  any  increased  action  of  the  heart  while  this  morbid 
change  is  in  progress,  the  weakened  walls  of  the  capillaries 
are  liable  to  give  way,  and  allow  the  blood  to  escape. 

The  extravasation  is  most  frequently  located  in  the 
corpus  striatum  and  optic  thalamus,  portions  of  the  cere- 
brum possessing  the  greatest  vascularity,  and  therefore 
more  liable  to  the  affection.  "When  the  blood  is  found.on 
the  surface,  the  meningeal  arteries  are  generally  ruptured, 
the  middle  meningeal  more  frequently  than  the  rest. 

The  coma  which  arises  from  laceration  of  diseased  arte- 
ries, in  most  instances,  is  sudden  in  its  development.  In 
very  rare  cases  there  are  premonitory  symptoms,  appearing 
in  the  shape  of  slight  facial  paralysis,  twitchings  of  the  mus- 
cles, local  points  of  anesthesia  in  the  extremities,  and  bleed- 
ing fi'om  the  nose.  In  some  cases  the  delicate  vessels  of 
the  retina  rupture,  and  produce  blindness.  This  occun-ed 
in  the  case  of  the  late  Dr.  George  T.  Elliot.     He  suffered 


120      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

from  retinal  apoplexy  several  mouths  previous  to  the  ex- 
travasations in  the  brain  which  ended  his  life. 

"When  the  attack  is  sudden,  the  patient  falls  to  the 
ground  insensible.  The  face  presents  a  congested  appear- 
ance ;  one  pupil  may  be  dilated  and  the  other  contracted, 
or  both  may  be  dilated.  They  will  not  act  readily  to  the 
stimulus  of  light.  If  the  clot  of  blood  involve  both  sides 
of  the  pons  Yarolii,  both  pupils  will  be  contracted.  Stra- 
bismus exists  in  many  cases.  The  respiration  is  labored 
and  stertorous ;  with  each  expiration  the  cheeks  are 
puffed  out,  as  in  the  act  of  blowing.  The  peculiar  noise,  or 
stertor,  accompanying  the  respiratory  movement,  is  due  to 
a  partial  paralysis  of  the  soft  palate  and  pillars  of  the 
fauces.  The  pulse  is  slow  and  full;  the  integument  is 
warm  and  moist,  but  there  is  no  increase  of  the  natural 
temperature  of  the  body.  Paralysis  of  one  side  {hemi^ple- 
gia)  is  usually  present.  When  both  sides  are  paralyzed,  the 
extravasation  will  be  found  in  the  2>ons.  In  the  face  the 
paralysis  is  indicated  by  a  drawing  down  of  the  angle  of 
the  mouth  on  one  side,  and  a  diminished  movement  on  the 
other,  or  perhaps  with  inability  to  close  the  eye  {lagopli- 
ttialmus). 

If  the  clot  involve  tlie  crura  cerebri  so  as  to  press  on  the 
third  pair  of  nerves,  there  will  be  inability  to  open  the  eye 
{ptosis),  divergent  strabismus,  and  dilatation  of  the  pupil 
on  the  side  opposite  to  the  general  paralysis.  Paralysis  of 
the  face  is,  in  the  majority  of  cases,  on  the  same  side  as  the 
hemiplegia.  Paralysis  of  the  extremities  is  seen  in  the 
different  effects  produced  by  counter-irritation,  one  limb 
moving  more  than  another  when  pounded  or  pricked.  An 
instrument  called  an  aesthesiometer  is  now  employed  to  as- 


LOSS  OF  CONSCIOUSNESS.  121 

certain  the  different  degrees  of  sensibility  existing  in  vari- 
ous parts. 

The  sphincter  muscles  which  guard  the  rectum  are  also 
paralyzed,  and  the  fasces  are  passed  involuntarily.  The 
orifice  of  the  bladder  is  guarded  by  elastic  fibres,  which 
retain  the  urine  when  the  sphincter  of  that  organ  is  para- 
lyzed. The  coma  which  follows  external  violence  presents 
similar  symptoms,  whether  connected  with  depressed  bone 
or  extravasated  blood. 

There  are  exceptional  cases  of  cerebral  extravasation 
which  do  not  exhibit  these  dangerous  characters  for  two  or 
three  days  succeeding  the  injury.  The  patient  may  have 
been  treated  for  a  slight  scalp-wound,  without  any  suspicion 
of  the  real  nature  of  the  lesion.  He  may  pursue  his  usual 
avocations  with  little  trouble  until  he  suddenly  sinks  into  a 
state  of  coma,  with  the  signs  of  compression  plainly  mani- 
fested. 

K  jpost-mortem  examination  in  these  cases  shows  that  the 
effused  blood  is  located  principally  at  the  base  of  the  brain, 
and  that  it  is  connected  with  fracture  of  the  base  of  the 
skull. 

When  coma  supervenes  three  or  four  days  after  an  in- 
jury, accompanied  by  an  increase  in  the  pulse  and  temper- 
ature, the  pressure  of  inflammatory  products,  such  as  serum, 
lymph,  or  pus,  may  be  suspected.  The  formation  of  pus, 
or  the  occurrence  of  pyaemia,  is  announced  by  severe  rigors. 

An  injury  to  the  head  may  be  followed  by  entirely  differ- 
ent symptoms  from  those  previously  described.  The  pa- 
tient may  have  concussion  of  the  brain  without  compression. 
There  is  loss  of  consciousness  in  both ;  but,  in  concussion, 
the  patient  is  more  easily  roused,  the  face  is  pale,  and  the 


122      EMERGENCIES,  AXD  HOW  TO  TREAT  THEM. 

surface  of  tlie  body  cold.  In  compression,  tlie  face  is  flushed 
and  tlie  body  warm.  Stertorous  breatliing  characterizes  the 
latter ;  in  tlie  former  the  respiration  is  natural  or  sighing. 
The  pulse,  in  concussion,  is  small  and  rapid ;  in  compression, 
it  is  slow  and  full.  The  pupils  are  generally  contracted  in 
concussion,  while  in  compression  they  are  dilated.  The  con- 
dition of  the  pupils,  however,  should  not  be  relied  on  in  di- 
agnosis, as  it  is  subject  to  much  variation.  In  compression 
of  the  brain,  there  is  usually  paralysis,  which  alone  is  suffi- 
cient to  distinguish  it.  In  rare  instances,  compression  and 
concussion  are  combined.  In  such  cases,  remedial  efforts  are 
mainly  dii-ected  to  relieve  the  former. 

It  is  necessary  to  diagnose  apoplectic  from  ursemic  coma. 
"With  the  latter  there  is  usually  a  history  of  Bright's  disease 
of  the  kidneys,  oedema  of  the  lower  extremities,  a  pale, 
waxy  countenance,  and  albumen  and  casts  in  the  urine.  In 
the  former,  these  signs  are  usually  absent.  Apoplectic 
coma  is  attended  by  paralysis  of  one  side  of  the  body,  and 
the  pupils  are  irregular.  In  ursemia  there  is  no  paralysis, 
and  both  pupils  are  dilated.  The  temperature  of  the  body 
is  said  to  be  higher  in  ursemia  than  in  apoplexy,  but  this 
cannot  be  depended  on  in  diagnosis.  "When  the  urinous 
odor  of  the  perspiration  exists,  we  have  further  evidence  of 
urasmia. 

Treatment. — ^Yery  little  can  be  done  to  relieve  the  coma 
which  results  from  the  rupture  of  diseased  arteries.  If  the 
patient  is  plethoric,  the  abstraction  of  a  few  ounces  of  blood 
from  the  arm  may  prevent  further  extravasation.  Authori- 
ties differ  as  to  the  utility  of  this  measure.  The  after- 
treatment  consists  in  the  prevention  of  inflammation  and 
the  administration  of  medicines,  which  assist  in  the  absorp- 


LOSS  OF  CONSCIOUSNESS.  123 

tion  of  the  clot.  For  the  latter  purpose,  iodide  of  potassium 
maj  be  administered  in  doses  of  from  five  to  ten  grains 
three  or  four  times  each  day.  If  the  stomach  is  disordered, 
or  an  eruption  of  the  skin  is  produced  by  its  use,  it  should 
be  discontinued.  If  inflammation  be  apprehended,  mustard- 
poultices  may  be  applied  to  the  nape  of  the  neck  and  to  the 
feet,  and  the  bowels  should  be  thoroughly  moved  by  an  ac- 
tive cathartic.  Croton-oil  and  elaterium  are  the  most  efficient. 

If  the  extravasation  proceed  from  a  blow  or  fall  on  the 
head,  the  operation  of  trephining  can  be  performed  in  one 
of  two  places,  viz. :  near  the  course  of  the  middle  meningeal 
artery  on  the  side  opposite  to  the  paralysis,  or  directly  un- 
derneath the  point  where  the  injury  was  inflicted.  A  cru- 
cial incision,  is  made  through  the  scalp,  which  is  turned 
back  and  the  bone  exposed.  The  skull  is  then  cut  carefully 
through  with  the  trephine.  If  the  blood  is  found  between 
the  dura  mater  and  the  bone,  it  is  readily  removed.  If  the 
membrane  swells  up  through  the  opening,  and  there  appears 
to  be  blood  underneath,  an  incision  can  be  made  through  it 
to  allow  its  escape.  After  the  operation,  the  wound  is  cov- 
ered, and  simple  water-dressings  applied.  The  usual  reme- 
dies, previously  mentioned,  to  prevent  inflammation,  are 
then  employed. 

When  the  coma  arises  from  depressed  fracture  of  the 
skull,  trephining  is  resorted  to,  or  the  depressed  bone  is 
raised  by  an  elevator. 

Coma  fkom  Embolism  Amy  Theombosis. — Inflammation 
of  the  valves  of  the  heart  and  atheromatous  degeneration 
of  the  aorta  are  attended  with  the  formation  of  fibrinous 
masses,  which  project  beyond  the  natural  dimensions  of  the 
artery  and  valve,  and  are  liable  to  be  washed  away  by  the 


124:  EMERGENCIES,   AND   HOW   TO   TREAT   TIIEM. 

current  of  blood.  Tliese  small  particles  may  be  carried  to 
the  brain  and  plug  up  one  of  tlie  cerebral  arteries,  cutting 
ofi*  the  supply  of  blood  from  that  portion.  The  artery  most 
frequently  involved  is  the  left  middle  cerebral.  The  plug  is 
called  an  embolus. 

Diminished  action  of  the  heart,  "with  loss  of  elasticity  in 
the  vralh  of  the  vessels,  may  predispose  to  the  formation  of 
a  clot  of  blood  {thrombus)  in  them.  The  supply  of  circulat- 
ing fluid  is  cut  off  as  in  the  former  case,  and  anaemia  of  the 
part  results.  Either  of  these  accidents,  taking  place  in  the 
brain,  may  produce  C07na.  In  some  cases  this  is  gradual,  in 
others  the  attack  is  sudden.  The  coma  differs  very  little 
from  that  which  depends  upon  cerebral  extravasation.  In 
coma  from  plugging  of  arteries,  the  face  is  usually  paler 
than  in  cerebral  extravasation,  and  there  is  with  it  some 
disease  of  the  mitral  or  aortic  valves.  Another  important 
point  in  the  diagnosis  is,. that  consciousness  is  restored  more 
rapidly  in  the  former  (often  within  two  or  three  days),  and 
that  the  paralysis  is  not  so  persistent. 

Treatment. — In  these  cases  we  can  only  wait  for  devel- 
opments. If  softening  of  the  brain  be  apprehended,  stimu- 
lants and  tonics  are  indicated.  Some  recommend  the  ad- 
ministration of  ammonia  to  absorb  the  clot  of  fibrine.  Its 
remedial  action  is,  however,  questionable. 

UKiEMic  Coma  results  from  the  same  poison  which  in- 
duces uraemic  convulsions.  Frerichs  developed  the  fact  that 
these  phenomena  were  caused  by  the  accumulation  of  urea 
in  the  blood,  and  its  subsequent  change  into  carbonate  of 
ammonia.  Spiegelberg,  a  later  investigator,  has  fully  con- 
firmed these  views  by  a  series  of  carefully-conducted  experi- 
ments. 


LOSS  OF  CONSCIOUSNESS.  125 

Urea  is  produced  by  tLe  decay  of  nitrogenized  tissue. 
It  is  eliminated  by  the  kidneys.  "When  tbese  organs  are 
diseased,  its  channels  of  escape  are  almost  wholly  closed,  and 
It  accumulates  in  the  blood.  There  it  is  decomposed,  one 
atom  of  urea  taking  two  atoms  of  water  from  the  blood,  and 
forming  by  this  combination  carbonate  of  ammonia. 

Ursemic  coma  occurs  during  the  progress  of  Briglit's  dis- 
ease of  the  kidneys,  and  may  have  all  the  symptoms  of  that 
affection  connected  with  it.  The  patient's  face  has  a  pale, 
waxy  look.  There  is  dropsical  effusion  in  the  cellular  tissue 
of  the  lower  eyelids,  and  behind  the  ankles,  or  over  the 
whole  of  both  lower  extremities.  The  urine  is  of  low  spe- 
cific gravity.  It  contains  albumen  and  casts.  Preceding 
the  coma  there  are  headache,  dimness  of  vision,  and  vomit- 
ing. The  patient  passes  into  a  somnolent  condition,  which 
hourly  increases,  until  a  state  of  profound  coma  is  reached. 
Sometimes  the  coma  is  preceded  by  a  convulsion,  without 
other  premonitions.  This  is  observed  especially  in  the  small 
contracted  kidney. 

The  coma  is  accompanied  by  a  certain  amount  of  ster- 
tor.  The  pupils  are  dilated,  but  not  irregular.  The  pulse 
is  more  rapid  than  usual,  and  lacks  firmness.  The  tempera- 
ture is  sometimes  slightly  increased. 

Poisoning  by  belladonna  presents  some  similarity  in  its 
symptoms  to  ursemic  coma.  The  pupils  in  both  are  widely 
dilated,  and  the  insensibility  is  profound.  The  history  of 
the  case,  and  the  absence  or  presence  of  signs  of  Bright's  dis- 
ease, determine  the  diagnosis. 

Treatment. — Our  principal  efforts  in  all  cases  is  to  elim- 
inate the  poison  from  the  system,  through  the  medium  of 
the  skin  and  bowels,  with  diaphoretics  and  active  cathartics. 


12(3      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Mix  equal  parts  of  croton-oil  and  ordinary  sweet-oil,  and 
apply  four  or  five  drops  of  tlie  mixture  to  the  back  of  the 
tongue.  This  can  be  done  by  moistening  the  end  of  a  pen- 
cil or  pen-handle  with  the  oil,  and  wiping  it  on  the  back 
of  that  organ.  It  is  not  well  to  use  the  croton-oil  undiluted, 
on  account  of  its  irritating  properties.  The  dose  should  be 
repeated  in  three-quarters  of  an  hour,  if  free  evacuations 
from  the  bowels  do  not  follow.  If  preferred,  elaterium 
may  be  administered  in  quarter-grain  doses  every  hour  until 
a  like  eflPect  is  produced.  In  connection  with  the  internal 
medication,  profuse  sweating  should  be  produced  by  means 
of  hot-air  baths.  Bottles  of  hot  water  and  warm  blankets, 
applied  to  the  surface,  answer  the  same  purpose.  The 
sweating  may  be  kept  up  for  a  considerable  time  without 
injury,  but  the  action  of  cathartics  must  be  guarded,  espe- 
cially if  the  constitution  be  much  weakened.  In  ordinary 
cases,  this  treatment  should  be  persevered  in  until  con- 
sciousness is  restored.  Prof.  A.  L.  Loomis  has  lately  em- 
ployed morphia  in  uraemic  coma.  He  administers  it  hy- 
podermically,  and  with  good  success.  Subsequently  the 
action  of  the  skin  may  be  kept  up  by  warm  baths  and  mild 
diaphoretics.  Tonics  and  nourishing  diet  are  also  necessary. 
To  sustain  the  action  of  the  kidneys,  and  at  the  same  time 
to  support  the  strength,  the  following  may  be  given  in  tea- 
spoonful  doses  four  or  five  times  a  day : 

B.   Hydrg.  bicMoridi gr- j« 

Tinct.  cinchonae  comp.        .  .        ,        .        fl.  |  iv.  M. 

The  internal  administration  of  benzoic  acid  was  at  one 
time  proposed  as  an  antidote  for  the  poison  of  urea ;  ex- 
periments, however,  did  not  warrant  a  continuance  of  its 


LOSS  OF  CONSCIOUSNESS.  127 

use.  When  ursemic  coma  is  the  result  of  acute  inflamma- 
tion of  the  kidneys,  the  treatment  varies.  In  addition  to 
the  ordinary  remedies,  the  application  of  wet  or  dry  cups 
over  these  organs  is  required,  and  is  generally  followed  by 
great  results. 

Rum  Coma. — '"When  large  quantities  of  alcohol  are  taken 
into  the  system,  a  state  of  insensibility  is  induced  which  in 
certain  particulars  resembles  the  other  varieties  of  coma. 
The  comatose  or  "  dead  drunk "  patient  lies  insensible, 
breathing  heavily.  The  respiration  has  more  of  the  char- 
acter of  a  snore  than  of  a  true  stertor.  The  pupils  are 
regular  and  act  to  light.  Sometimes  they  are  dilated. 
In  the  early  part  of  the  coma  the  pulse  is  soft  and  in- 
creased in  frequency,  but  afterward  becomes  slower.  The 
breath  usually  smells  strongly  of  alcohol.  Too  much  re- 
liance, however,  must  not  be  placed  on  this  sign  until  the 
history  of  the  case  is  examined  into,  for,  in  cases  of  sudden 
insensibility,  by-standers  are  in  the  habit  of  administering 
stimulants.  The  patient  usually  has  been  drinking  freely 
for  some  time,  and  the  stupor  appears  gradually,  preceded 
by  a  staggering  gait,  and  other  signs  of  drunkenness.  Coma 
due  to  compression  of  the  brain  may  be  excluded,  if  there 
is  no  paralysis  or  irregularity  of  the  pupils,  or  complete 
coma.  Erom  ursemic  coma  it  is  diagnosed  by  the  absence 
of  oedema  of  the  eyelids  and  lower  extremities,  of  albumen 
or  casts  in  the  urine,  or  urinous  odor  in  the  perspiration 
Besides,  ursemic  coma  is  profound,  while  coma  from  rum 
is  only  partial.  If  the  patient  had  a  convulsion  previous 
to  the  coma,  and  no  signs  of  Bright's  disease  present, 
the  case  might  readily  be  mistaken  for  true  epilepsy. 
Our  main  reliance  under  such  circumstances  must  be  the 


12S      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

liistorj  of  the  case  and  tlie  surroundings  of  the  patient.  If 
the  tongue  has  not  been  bitten,  and  there  is  a  history  of  a 
spree,  we  may  then  exclude  epilepsy. 

Treatment. — If  an  emetic  of  mustard  can  be  admin- 
istered, and  the  stomach  emptied,  much  good  will  result. 
Subsequent  applications  of  cold  water  to  the  head  and  chest 
will  be  beneficial. 

IIystekical  Coma  is  one  of  the  manifestations  of  the 
hydra-headed  nervous  affection  hysteria,  a  disease  peculiar 
to  nervous  women.  Scientific  investigation  has  not  yet 
reached  the  morbid  changes  which  occasion  the  disease.  Its 
real  nature  is  still  in  the  dark.  "We  know  that  it  is  charac- 
terized by  a  morbid  sensitiveness,  a  tendency  to  imitate  dis- 
ease, and  that  it  is  to  a  certain  extent  under  the  control  of 
the  will,  but  farther  we  cannot  go. 

The  patient  imagines  she  has  a  disease,  but  the  practised 
eye  detects  the  counterfeit.  She  may  simulate  paralysis, 
and  remain  in  bed  for  months.  All  the  pains,  aches,  and 
diseases,  which  "  flesh  is  heir  to,"  may  be  represented  and 
imitated  without  limit,  and  yet  these  unfortunates  cannot 
be  charged  with  fraud.  The  case  of  a  young  hysterical 
patient,  who  was  at  one  time  in  Ward  24,  Bellevue 
Hospital,  furnished  an  excellent  example  of  this  class.  On 
her  admission,  she  was  placed  near  a  patient  in  the  last 
stages  of  Eright's  disease.  In  a  few  hours  afterward,  I 
found  her  suffering  from  nearly  every  prominent  symptom 
exhibited  by  her  dying  neighbor.  The  condition  lasted  for 
a  few  days,  when  the  ambitious  young  woman  developed 
the  signs  of  peritonitis,  and  managed  to  keep  them  up  for 
two  or  three  weeks.  Subsequently,  she  passed  to  the  care 
of  another  house-physician,  and  I  lost  sight  of  her.     In  an- 


LOSS  OF  CONSCIOUSNESS.  129 

other  ward  of  the  same  hospital  was  a  young  Irish  girl  who 
suffered  from  retention  of  urine.  The  catheter  was  regular- 
ly employed  for  several  days  before  the  real  nature  of  the 
disease  was  discovered.  Her  will,  or  her  disease,  enabled  her 
to  remain  three  days  without  passing  water.  At  the  end  of 
that  period  she  relieved  herself  naturally,  and  continued  to 
do  so  afterward.  The  same  patient  afterward  developed 
paralysis  of  the  lower  extremities,  which  lasted  several 
months.  Temporary  recovery  took  place  during  a  thunder- 
storm. The  noise  alarmed  her  so  that  she  forgot  her  paraly- 
sis and  sprung  out  of  bed.  It  returned  again  in  a  milder 
form,  but  gradually  wore  away.  When  discharged  from  the 
hospital,  she  was  entirely  cured. 

Hysterical  coma  is  a  comparatively  rare  manifestation 
of  the  disease.  It  is  often  preceded  by  general  excitability, 
and  by  spells  of  violent  laughter  and  crying  without  assign- 
able cause.  There  is  often  a  sense  of  choking  {globus  hys- 
tericus), due  to  contractions  of  the  oesophagus,  from  below 
upward.  It  gives  a  feeling  as  if  a  ball  were  rising  in  the 
throat.  Previous  to  the  coma  there  may  have  been  a  con- 
vulsion, but  it  is  not  always  an  accompaniment. 

The  patient,  during  the  attack,  lies  motionless,  and  to 
all  appearance  unconscious.  The  breathing  is  natural. 
There  is  no  lividity  or  other  unnatural  condition  of  the  face. 
An  examination  of  the  eyes  will  show  that  the  patient  sees 
all  that  is  passing  around  her,  and  that  the  pupils  act  to 
light.  The  pulse  is  natural  in  all  respects.  The  absence  of 
stertorous  breathing,  insensibility,  and  irregularity  in  the 
pupils,  suffices  to  show  that  there  is  no  compression  of  the 
brain  or  other  serious  affections. 

Treatment. — For  hysterical  coma,  the  cold  douche  is  tlie 
9 


130  EMERGENCIES,  AND  HOW  TO   TREAT  TEEM. 

best  known  remedy.  Two  or  three  pitchers  of  cold  water, 
poured  from  a  height  upon  the  face,  will  generally  suffice  to 
bring  about  a  recover3\  The  after-treatment  consists  in 
developing  self-control,  sustaining  the  general  health  with 
fresh  air  and  good  food,  the  removal  of  any  existing  disease 
of  the  generative  apparatus,  and  the  administration  of  anti- 
spasmodics, as  musk,  valerian,  assafoetida,  etc. 

Epileptic  Coma  follows  an  epileptic  convulsion.  The 
insensibility  is  never  complete.  Blood  may  collect  on  the 
lips.  There  is  laceration  of  the  tongue.  The  sudden  oc- 
cuiTence  of  the  convulsion  when  the  patient  is  in  good 
health  otherwise,  and  the  complete  recovery  when  the  attack 
has  passed  away,  serve  to  distinguish  this  disease  in  all 
cases.     {See  article  on  Epileptic  Convulsions.) 

Treatment. — Epileptic  coma  does  not  require  treatment. 
To  prevent  a  recurrence  of  the  convulsion,  bromide  of  po- 
tassium can  be  given.  Ten  grains,  four  times  a  day,  will  be 
enough  for  an  adult. 

CONCUSSION   OF   THE   BKAIN. 

Concussion  of  the  brain  may  be  defined  as  a  shaking  to- 
gether of  the  contents  of  the  cranial  cavity,  with  more  or 
less  contusion  of  the  brain-substance,  and  attended  by  par- 
tial or  complete  unconsciousness.  The  injury  may  be  pro- 
duced by  direct  blows  upon  the  head,  or  by  jumping  from  a 
height  and  alighting  on  the  heels,  the  force  in  the  latter 
case  being  transmitted  through  the  spinal  column. 

In  some  cases  the  most  careful  examination  of  the  brain 
after  death  fails  to  detect  signs  of  contusion.  In  the  major- 
ity, however,  minute  points  of  extravasation,  discoloration. 


LOSS  OF  CONSCIOUSNESS.  131 

and  softening  of  small  portions  of  the  nerve-substance,  are 
found. 

Millar,  Wood,  and  others,  divide  concussion  into  three 
stages:  1.  That  of  insensibility ;  2.  Eeaction;  and  3.  Ex- 
cessive reaction  or  inflammation.  The  symptoms  attending 
the  first  stage  vary  with  the  amount  of  concussion.  In  typ- 
ical cases,  the  patient  falls  unconscious  after  receiving  the 
injury.  The  skin  is  pale  and  cold,  and  the  pulse  small  and 
rapid.  Kespiration  is  natural  or  sighing.  The  pupils  are 
contracted,  or  one  may  be  contracted  and  the  other  dilated. 
The  sphincter  muscles  are  not  often  interfered  with. 

In  the  second  stage,  the  patient  vomits  and  shows  evi- 
dences of  returning  consciousness.  The  pulse  becomes 
stronger,  warmth  returns  to  the  body,  and  slight  color  to 
the  lips  and  cheeks.  If  this  reaction  be  excessive,  showing 
a  tendency  to  inflammation,  the  third  stage  is  ushered  in. 
The  skin  becomes  dry  and  hot,  and  there  is  considerable 
headache.  The  pulse  rises,  and  is  firmer  than  during  the 
preceding  stages.  Finally,  if  the  case  progresses  unfavor- 
ably, all  the  signs  of  meningitis  are  manifested,  such  as  in- 
tolerance of  light,  intense  headache,  contracted  pupils,  sub- 
sultus  tendinum,  delirium,  and  finally  coma.  The  difieren- 
tial  diagnosis  between  compression  of  the  brain  and  con- 
cussion has  already  been  given. 

In  many  instances,  the  concussion  is  extremely  slight, 
lasting  but  a  few  moments.  This  is  the  case  where  the  pa- 
tient is  merely  stunned,  and  the  efifect  soon  passes  away.  In 
other  cases,  the  concussion  is  so  great  as  to  cause  instant 
death. 

Treatment. — If  there  be  collapse,  hot  bottles  and  blank- 
ets are  to  be  applied  to  the  extremities,  and  the  circulation 


132      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

stimulated  by  frictioa  with  tlie  hands.  Diluted  enemata  of 
brandy  and  ammonia  arc  also  serviceable.  All  stimulating 
efibrts  must  cease  as  soon  as  reaction  retm'ns.  Should  in- 
flammation set  in,  the  ordinary  antiphlogistic  treatment, 
previously  referred  to,  will  be  necessary. 


CHAPTER  XI. 

LOSS    OF    COJf  scions  JffFSS-iCoi^TmvsD). 
SYNCOPE. 

Syncope  from   Hsemorrliage. — Thrombi   in  tlie  Pulmonaiy  Vein. — Anoemia.— 
Mental  Emotion. — Blows  on  the  Epigastrium. — Collapse. 

The  normal  performance  of  every  function  depends  on 
an  adequate  supply  of  healthy  blood.  The  delicate  ma- 
chinery ceases  when  the  proportion  to  each  part  is  not  com- 
mensurate with  its  demands. 

The  continuous  pulsatory  movements  of  the  heart  propel 
the  blood  into  the  vessels  which  carry  it  to  all  parts  of  the 
body.  A  partial  or  complete  cessation  of  the  action  pro- 
duces a  condition  known  as  syncope,  or  fainting.  This  is 
characterized  by  unconsciousness,  and  by  suspension  of  the 
powers  of  volition. 

•  The  regular  contractions  of  the  heart  depend  upon 
several  conditions :  1.  A  sufficient  and  regular  supply  of 
blood,  which  exercises  a  stimulating  effect  on  its  fibres  ;  2. 
A  normal  proportion  of  the  necessary  ingredients  in  the 
circulating  fluid  ;  3.  A  healthy  state  of  the  brain  and  of  the 
nerves  and  sympathetic  ganglia  which  supply  the  heart ;  4. 
A  special  irritability  possessed  by  the  muscular  fibres,  which 
causes  its  contractions  to  continue  even  when  all  connection 


134:      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

with  the  body  has  been  severed,  and  the  extraneous  sources 
of  stimuhition  removed. 

This  innate  power  is,  for  want  of  a  better  name,  denomi- 
nated irritability.  Of  its  nature  "we  are  totally  ignorant. 
In  cold-blooded  animals  it  is  particularly  noticeable.  Any 
morbid  change,  which  directly  or  indirectly  disturbs  the  con- 
ditions spoken  of,  is  liable  to  induce  syncope. 

Syncope  is  produced  by  excessive  haemorrhage.  This, 
however,  when  not  too  prolonged,  is  rather  of  benefit  than 
otherwise.  The  cessation  in  the  movements  of  the  heart 
allows  the  blood  to  coagulate  in  the  bleeding  vessels,  and 
prevents  the  possibility  of  htemorrhage  when  the  circula- 
tion is  renewed. 

Thi'ombi  in  the  pulmonary  vein  causes  fatal  syncope  by 
preventing  the  blood  from  passing  through  the  lungs  to  the 
left  side  of  the  heart,  and  by  producing  distention  of  the 
right  am'icle  and  ventricle. 

Syncope  arising  from  a  deficiency  in  the  ordinary  stimu- 
lating ingredients  of  the  blood  is  witnessed  sometimes  in 
ansemia,  and  in  chlorosis.  In  these  diseases  the  watery 
portions  of  the  blood  are  increased,  the  red  corpuscles  are 
diminished,  the  circulation  being  at  all  times  exceedingly 
feeble.  In  leucocy  thsemia,  where  there  is  a  very  great  excess 
of  white  corpuscles,  and  in  phthisis,  where  there  is  much 
general  deterioration  of  the  blood,  sudden  failure  of  the 
heart's  action  is  likely  to  occur  after  rapid  exertion. 

Syncope  likewise  results  from  mental  emotions,  such  as 
sudden  joy,  anger,  grief,  etc.  These  act  in  some  peculiar 
and  unknown  manner  upon  the  nerves  of  the  heart,  sus- 
pending their  influence.  In  some  cases  the  emotion  has 
been  so  great  as  to  destroy  life. 


LOSS  OF  CONSCIOUSNESS.  135 

Anaemia  of  tlie  brain  and  concussion  are  attended  with 
syncox^e.  Blows  on  the  epigastrium  may  injure  the  solar 
plexus,  and  cause  a  fatal  reflex  paralysis  of  the  heart.  The 
cases  of  sudden  death  from  drinking  cold  water  while  per- 
spiring are  similarly  accounted  for. 

Sedatives  may  induce  syncope  if  the  doses  are  large  or 
too  frequently  repeated.  The  majority  of  sedatives,  such  as 
tobacco,  colchicum,  antimony,  prussic  acid,  etc.,  act  by  di- 
minishing the  nerve-force.  Some  consider  that  digitalis  acts 
on  the  heart  as  a  tonic,  and  not  as  a  sedative.  It  is  hard  to  '  y^- 
harmonize  with  this  theory  the  authenticated  cases  of  syncope, 
or  collapse,  following  its  use  in  the  usual  medicinal  doses. 

Chloroform,  when  administered  to  debilitated  individuals, 
may  act  directly  upon  the  nerves  of  the  heart,  and  cause 
paralysis  of  that  organ.  Chloroform  usually  kills  by  acting 
through  the  lungs  and  producing  asphyxia,  or  through  the 
brain,  causing  coma. 

Severe  burns,  cruslied  limbs,  surgical  operations,  etc., 
are  sometimes  followed  by  sudden  partial  suspension  of 
the  functions  of  the  nervous  system,  and  diminished  action 
of  the  heart,  which  is  commonly  known  as  shock  or  collapse. 
Although  in  many  essential  points  resembling  ordinary  syn- 
cope, there  are  important  differences  which  distinguish 
them.  The  duration  of  syncope  is  more  brief.  The  pa- 
tient either  dies  suddenly  or  recovers  rapidly.  Collapse 
is  prolonged.  Syncope  is  attended  with  unconsciousness 
and  loss  of  voluntary  motion.  In  collapse  the  patient  is 
not  completely  insensible,  the  mind  is  to  a  certain  extent 
clear,  and  the  power  of  voluntary  movement  remains. 

Other  varieties  of  syncope  arise  from  disease  of  the 
heart  or  its  coverings.     Among  them  are  fatty  degeneration 


i3G  EMERGENCIES,   AND   ROW   TO   TREAT   TIIEM. 

of  tlie  muscular  fibres,  angina  pectoris,  and  pericarditis,  with 
efi'usiori. 

Persons  of  delicate  frame  and  sensitive  nervous  organiza- 
tions are  most  subject  to  syncope.  Women  arc  alfected 
more  frequently  than  men.  Feeble  woraen,  Avith  uterine 
disorders,  will  faint  from  slight  injury,  or  any  unusual 
mental  excitement. 

The  symptoms  of  syncope  are  clearly  marked.  The 
patient  is  conscious  of  a  sinking  sensation  in  tlie  epigastric 
region,  and  about  the  heart.  There  are  dizziness,  dimness 
of  vision,  and  ringing  in  the  ears  (tinnitus  au7num).  The 
features  are  pinched,  and  the  lips  and  clieeks  are  pale  and 
cold.  Tlie  pulse,  at  first  small  and  fluttering,  is  at  last  im- 
perceptible. An  impulse  can  scarcely  be  recognized  in  the 
prsecordial  region.  There  is  also  partial  or  complete  uncon- 
sciousness. Itespiratory  movements  may  cease  altogether, 
or  a  spasmodic,  irregular  sighing  is  present. 

The  attack  lasts  from  a  few  seconds  to  two  or  three 
minutes.  It  is  very  rarely  prolonged  beyond  two  minutes. 
Resuscitation  would  not  be  possible  if  the  heart's  pulsations 
were  absent  for  five  minutes  ( Walsh). 

Kecovery  is  announced  by  attempts  at  swallowing,  by 
sighing,  movements  of  the  body,  restoration  of  warmth  and 
color  to  the  cheeks,  and  a  return  of  the  radial  pulse.  In 
some  cases  the  attack  may  terminate  with  nausea  and 
vomiting. 

Although  in  most  cases  syncope  is  easy  of  recognition, 
mistakes  are  sometimes  made  and  erroneous  opinions  given. 
It  is  therefore  well  to  consider  the  morbid  states  for  which 
it  may  be  mistaken. 

There  is  a  class  of  persons  called  malingerers^  who,  from 


LOSS  OF  CONSCIOUSNESS.  I37 

Bordid  or  other  motives,  feign  various  forms  of  illness,  and 
syncope  is  sometimes  simulated.  Prostitutes  or  disorderly 
characters,  in  order  to  escape  detention  in  the  station-house, 
or  a  subsequent  visit  to  Blackwell's  Island,  work  on  the 
sympathies  of  the  police  oflScial,  until  a  carriage  is  ordered, 
and  they  are  conducted  to  the  hospital.  Once  there,  unless 
the  doctor  in  attendance  is  particularly  disgusted  with  the 
performance,  the  patient  will  likely  be  discharged  the  next 
day  without  trouble.  These  cases  are  readily  recognized 
by  the  fact  that  the  pulse  is  beating  with  its  accustomed 
fulness  and  regularity,  that  the  temperature  of  the  body  is 
normal,  and  that  an  announcement  of  an  intention  to  draw 
blood  from  the  arm,  or  shave  the  head  and  apply  ice,  is  fol- 
lowed by  an  avowal  of  the  patient  that  she  is  much  better, 
and  will  not  require  further  treatment. 

Ordinary  syncope  is  readily  distinguished  from  hysterical 
stupor  by  the  fact  that  the  patient  has  not  lost  conscious- 
ness, nor  is  the  action  of  the  heart  or  pulse  specially  altered. 

Poisoning  from  carbonic  acid  gives  a  dark,  livid  color  to 
the  countenance,  the  insensibility  is  continuous,  and  the 
pulse  can  be  felt  in  the  wrist.  Poisoning  from  urea,  or 
Bright's  disease,  is  diagnosed  by  the  accompanying  dropsi- 
cal swelling  of  the  lower  limbs,  urinous  odor,  and  the  pres- 
ence of  casts  and  albumen  in  the  urine. 

A  person  in  a  state  of  deep  syncope  may  be  considered 
dead,  but  if  the  characteristic  signs  of  death  are  understood, 
little  difficulty  will  be  experienced  in  making  a  correct 
diagnosis.     {See  article  on  Asphyxia,  page  147.) 

Treatment. — In  mild  cases,  where  the  patient  is  only 
partially  unconscious,  stimulating  inhalations  of  eau-de- 
cologne,  vapor  of  ammonia,  sprinkling  the  head  and  face 


13S      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

with  cold  water,  or  placing  the  patient  in  a  cold  draught  of 
air,  will  suffice  to  restore  sensibility. 

Where  there  is  complete  unconsciousness,  more  urgent 
measures  will  be  necessary.  In  all  cases,  the  patient  should 
be  placed  in  the  recumbent  position,  with  the  head  lower 
than  the  shoulders.  This  is  done  in  order  that  the  blood 
flowing  toward  the  cerebrum  may  have  the  assistance  of 
gravitation,  and  also  to  accelerate  the  current  travelling 
from  the  lower  extremities  toward  the  heart.  All  super- 
fluous clothing  should  be  removed  from  the  chest  and  throat. 
Collars,  neck-ties,  and  other  articles  which  constrict  the 
neck,  hinder  recovery.  The  stimulating  inhalations  of  am- 
monia, etc.,  are  of  little  avail  in  complete  syncope,  for  there 
is  scarcely  any  respiratory  movement;  the  nostrils,  how- 
ever, may  be  moistened  with  the  liquid.  Cold  water, 
thrown  violently  in  the  face,  or  sprinkled  forcibly  on  the 
chest,  striking  the  palms  of  the  hands,  and  rubbing  them 
rapidly,  are  efficacious  in  all  cases.  An  efficient  remedy  is 
to  dip  a  plate  in  hot  water  and  place  it  over  the  epigastric 
or  proecordial  regions ;  either  place  will  answer.  All  these 
methods  may  be  combined  in  the  treatment  of  individual 
cases.  Should  they  fail,  galvanism  may  be  carefully  tried. 
Too  much  is  worse  than  too  little.  One  pole  of  the  battery 
may  be  placed  at  the  upper  part  of  the  spinal  column,  and 
the  other  moved  up  and  down  over  the  sternum  and  prae- 
cordia.  The  poles  may  also  be  applied  along  the  course  of 
the  spinal  accessory  nerve.  The  action  of  the  heart  has  in 
some  cases  been  renewed  by  exciting  the  spinal  accessory 
and  the  four  upper  cervical  nerves  ( Vale?itm). 

The  treatment  of  syncope  resulting  from  excessive  haem- 
orrhage has  been  discussed  in  a  preceding  chapter. 


CHAPTER  XII. 

ASPHYXIA. 

EeBpiratory  Apparatus.— Effects  of  Non-aeration  of  Blood.— Strangulation.— Com- 
pression of  Thorax.— Inhalation  of  Poisonous  Gases.— Signs  of  Death.— 
Drowning, 

The  pathological  changes  arising  from  defective  aeration 
will  be  better  understood  if  we  glance  briefly  at  the  pro- 
cesses which  regulate  the  supply  of  oxygen,  and  the  elimi- 
nation of  carbonic  acid.  To  describe  in  detail  these  impor- 
tant phenomena  would  lead  us  beyond  the  prescribed  limit 
of  this  work,  We  must  confine  our  attention  to  such  as 
have  a  special  bearing  upon  the  morbid  actions  in  question. 

The  respiratory  apparatus  comprises  the  larynx,  trachea, 
bronchi,  and  lungs.  The  lungs,  the  heart,  and  great  vessels, 
are  contained  within  the  cavity  of  the  thorax  or  chest.  A 
large,  flat  muscle,  called  the  diaphragm,  forms  the  floor  of 
this  cavity  and  separates  it  from  the  abdomen.  Each  lung 
is  composed  of  bronchial  tubes,  air-cells,  vessels,  and  nerves. 
The  bronchial  tubes  commence  at  the  termination  of  the 
trachea.  They  divide  and  subdivide,  becoming  smaller  as 
they  pass  in,  until  they  terminate  with  a  diameter  of  -^  of 
an  inch  in  the  intercellular  passages  or  bronchioles.  Around 
these  passages  and  terminal  bronchi,  the  air-cells  are  clus- 
tered in  a  manner  similar  to  the  arrangement  of  "  leaves  on  a 


140  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

tree-branch."  These  cells  measure  from  tj^  to  -g-J-g-  of  an  inch 
each  in  diameter.  They  are  formed  of  a  delicate  layer  of 
mucous  membrane,  closely  attached  to  which  are  minute 
plexuses  from  the  pulmonary  artery  and  veins,  and  to  unite 
the  whole  there  is  a  quantity  of  yellow  elastic  tissue. 

According  to  the  calculation  of  M.  Eocheaux,  there  are 
17,Y90  air-cells  connected  with  each  terminal  bronchus,  and 
in  the  lungs,  600,000,000.  Prof.  Dalton,  of  this  city,  esti- 
mates the  amount  of  surface  thus  exposed  to  the  action  of  the 
air,  at  1,400  square  feet.  The  capillary  vessels  of  the  pulmo- 
nary artery  and  pulmonary  veins  distributed  in  delicate 
meshes  on  the  walls  of  the  air-cells  are  the  channels  through 
which  the  blood-changes  are  effected.  The  venous  blood, 
loaded  with  carbonic  acid,  is  carried  by  the  pulmonary  ar- 
teries from  the  right  side  of  the  heart  to  the  lungs,  where  it 
gives  up  its  load  of  impurity.  The  capillaries  of  the  pul- 
monary veins,  which  originate  in  the  walls  of  the  air-cells, 
take  up  the  renovated  blood  with  its  load  of  oxygen,  and 
carry  it  to  the  left  side  of  the  heart,  whence  it  is  propelled 
to  all  parts  of  the  body. 

The  interchange  of  gases  and  aeration  of  the  blood  are 
effected  during  the  respiratory  movements  of  inspiration 
and  expiration.  During  inspiration,  the  diaphragm  con- 
tracts and  increases  the  vertical  diameter  of  the  chest, 
while  the  ribs  are  elevated  and  separated  by  the  action  of 
the  other  inspiratory  muscles,  thereby  making  the  lateral 
diameters  greater.  A  vacuum  is  thus  formed,  and  the  air 
rushes  in.  Following  immediately  is  an  expiratory  move- 
ment, in  which  the  air  is  forced  out :  1.  By  the  relaxation 
of  the  diaphragm,  which  is  pushed  upward  by  the  abdom- 
inal organs  resuming  their  original  positions ;   2.  The  ribs 


ASPHYXIA.  141 

are  drawn  together  by  the  external  intercostals  ;  and  3.  The 
lungs,  which  are  extremely  elastic,  contract  and  force  the 
air  out  of  the  cells.  After  the  air  enters  the  bronchial 
tubes,  a  diffusion  of  gases  takes  place,  and  the  impure  air 
below  passes  upward,  while  the  oxygen  continues  on  to  the 
air-cells.  After  reaching  the  cells,  the  oxygen  passes  by  en- 
dosmosis  through  to  the  blood,  and  is  carried  off  by  the  cor- 
puscular elements  of  the  circulatory  fluid  which  have  pre- 
viously given  up  their  carbonic  acid.  Allowing  that  twenty 
respiratory  movements  take  place  in  a  minute,  the  air  in  the 
lungs  will  be  necessarily  changed  1,200  times  in  the  course 
of  an  hour.  About  17  cubic  feet  of  oxygen  are  consumed  in 
24  hours,  and  during  the  same  period  from  300  to  400  cubic 
feet  of  atmospheric  air  are  supplied  to  the  lungs. 

Oxygen  gas  is  an  essential  requirement  of  a  healthy 
organism.  It  exerts  a  remarkable  influence  upon  both 
vegetable  and  animal  life.  Eight-ninths  of  the  whole  mass 
of  water,  one-third  of  the  earth's  substance,  and  one-fifth  of 
the  atmosphere,  are  composed  of  oxygen :  no  element  is  more 
abundant  or  more  important. 

Eepair  and  decay  are  closely  linked  in  the  animal 
economy.  Death  is  a  necessary  accompaniment  of  life. 
Molecular  disorganization,  elaboration,  and  growth  of  new 
material,  proceed  simultaneously.  In  health  the  growth 
keeps  pace  with  loss,  in  disease  waste  preponderates.  Dm-- 
ing  the  physiological  interchange  of  material  new  sub- 
stances of  a  poisonous  nature  are  generated,  and  are  removed 
by  the  different  emunctories.  Should  the  avenues  of  escape 
be  closed,  life  is  speedily  terminated.  For  instance,  the 
kidneys  eliminate  an  excrementitious  substance  called  iirea^ 
which  is  formed  by  the  decay  of  nitrogenized  tissue.    When 


142      EMERGENCIES,  AND  HOW  TO  TREAT  TDEM. 

these  organs  cease  to  abstract  tLis  material  from  the  blood, 
it  accumulates  and  produces  convulsions,  coma,  and  finally 
death.  Carbonic  acid,  which  is  specially  under  considera- 
tion in  this  connection,  is  another  product  of  retrograde 
metamorphosis.  "Wlien  through  disease  or  accident  it  is 
retained,  and  the  blood  imperfectly  aerated,  all  the  nutri- 
tive processes  are  retarded,  or  entirely  stopped.  The 
vitality  of  the  body  necessarily  fails  to  approximate  to  a 
healthy  standard,  and  latent  germs  of  disease  are  impelled 
to  an  inordinate  and  even  fatal  growth. 

The  large  mortality  in  our  tenement-houses  is  sufficient 
evidence  of  this  truth.  Human  beings  are  crowded  together 
in  these  dens,  in  a  stifling  atmosphere,  unfit  to  supply  the 
wants  of  the  system.  A  family  of  six  and  seven  will  some- 
times be  cramped,  in  one  or  two  small  rooms,  scarcely  large 
enough  to  accommodate  a  single  person.  But  it  is  not  alone 
the  evil  of  a  diminished  quantity  of  oxygen  that  these 
people  have  to  contend,  with ;  the  surrounding  atmosphere 
is  rendered  doubly  poisonous  by  the  animal  exhalations 
which  naturally  accumulate  and  occasion  cholera,  typhus 
fever,  and  other  pestilences.  In  these  homes  of  the  poor, 
these  monuments  to  the  grasping  spirit  of  the  nineteenth 
century,  death  reaps  a  rich  and  continuous  harvest.  And 
all  this  must  endure  until  the  strong  ar^i  of  the  law  compels 
avaricious  landlords  to  construct  houses  properly  ventilated, 
and  fit  for  human  habitation. 

As  an  example  of  the  efiects  of  imperfect  ventilation,  the 
sufibcation  of  a  large  number  of  persons  in  the  famous  oi 
rather  infamous  "  Black  Hole  of  Calcutta,"  will  be  remem- 
bered. One  hundred  and  fifty  persons  were  confined  for  a 
single  night  in  a  room  eighteen  feet  square,  having  but  one 


ASPHYXIA.  143 

Binall  window.  In  tlie  morning  onlj  seventeen  were  alive. 
As  another  example  of  the  evils  attending  imperfect  ventila- 
tion, we  may  mention  the  destruction  of  life  which  occurred 
on  an  Irish  steamer  some  years  ago  while  crossing  the 
Channel.  During  a  storm  the  captain  compelled  one  hun- 
dred and  fifty  of  the  passengers  to  go  below,  and  afterward 
closely  fastened  down  the  hatchways.  Seventy  persons 
perished  before  the  hatchways  were  removed.  The  violent 
storm  prevented  their  outcries  from  being  heard,  otherwise 
their  horrible  fate  might  have  been  averted. 

Similar  occurrences,  but  on  a  smaller  scale,  are  fre- 
quently brought  to  our  notice.  They  generally  arise  from 
design  or  neglect. 

The  condition  resulting  from  a  complete  cessation  of  the 
respiratory  movements  is  usually  known  as  asphyxia  or 
aprtijea.  The  word  asphyxia,  derived  from  two  Greek  words 
signifying  pulselessness,  does  not  define  the  condition.  Ap- 
ncea  indicates  the  prominent  features  of  the  morbid  pro- 
cess with  greater  accuracy ;  but,  as  asphyxia  is  the  word  in 
general  use,  it  will  be  adhered  to  in  the  present  chapter. 

The  first  effect  of  obstructing  the  entrance  of  air  is  a  re- 
tardation of  the  current  of  blood  in  the  capillary  vessels  of 
the  lungs  and  general  system.  The  blood  accumulates  and 
moves  slowly  through  them.  Should  the  ingress  of  air  be 
still  further  prevented,  this  state  of  congestion  ends  in  com- 
plete stagnation  or  stoppage  of  the  circulation.  Unaerated 
blood  cannot  pass  through  the  capillaries. 

Prof.  Austin  Flint,  Jr.,  considers  the  want  of  oxygen 
in  the  tissues,  and  the  accompanying  capillary  congestion, 
as  the  starting-point  of  suffocation  or  asphyxia  /  and 
that  the  obstruction  in   the   capillaries   throws  the  blood 


1^-1,  EMERGENCIES,   AND  HOW   TO   TREAT  THEM. 

back  on  the  heart,  and  overpowers  it,  so  that  it  entirely 
ceases. 

Some  consider  that  the  congestion  of  the  lungs  is  alone 
the  cause  of  death ;  others,  that  the  blood  going  to  the 
brain,  loaded  with  carbonic  acid,  destroys  the  activity  of  the 
cerebrum,  and  through  it  acts  upon  the  heart  and  the  nerves 
supplying  that  organ. 

Where  so  many  phenomena  exist,  involving  different 
vital  parts,  it  is  ahuost  impossible  to  separate  them,  and 
definitely  say  which  is  the  cause  of  death.  To  repeat,  defec- 
tive aeration  causes  the  rapid  increase  of  carbonic  acid,  and 
induces  capillary  congestion  in  every  part  of  the  system ;  this 
congestion  demands  more  labor  from  the  heart,  and  the  con- 
gestion of  the  lungs  increases  the  difficult  respiration,  and 
makes  it  more  labored.  The  blood,  which  is  loaded  with 
carbonic  acid,  necessarily  obtuuds  nervous  sensibility,  and, 
acting  through  the  cardiac  nerves  upon  the  heart,  combines 
with  the  other  morbid  influences  in  weakening  the  contrac- 
tions of  that  organ,  and  bringing  about  a  fatal  tennination. 

The  morbid  appearances  after  death  vary  but  little  with 
the  cause  of  the  asphyxia.  In  the  majority  of  cases  there 
is  a  similarity  in  the  changes.  The  face  generally  is  of  a 
dark,  livid  color ;  froth  or  foam,  streaked  with  blood,  sur- 
rounds the  mouth.  The  eyes  protrude.  In  suffocation  from 
hanging,  the  tongue  is  swollen  and  pushed  out  between  the 
lips  Rigor  mortis  appears  soon  after  death.  The  lungs 
are  heavy  and  dark,  and  contain  a  large  quantity  of  black 
blood.  The  air-cells  and  smaller  bronchial  tubes  are  filled 
with  a  sanious,  frothy  fluid.  Blood  is  absent  from  the  left 
side  of  the  heart  and  arteries.  This  latter  peculiarity  is  due 
to  the  elasticity  of  the  walls  of  the  arteries  forcing  out  the 


ASPHYXIA.  145 

blood.  It  is  not  confined  especially  to  death  from  suffoca- 
tion, but  occurs  in  otlier  forms. 

The  auricle  and  ventricle  on  the  left  side  of  tlie  heart 
are  distended  with  dark  blood,  and  all  the  blood  in  the  body 
is  blacker  than  under  ordinary  circumstances.  This  is 
caused  by  the  absence  of  oxygen,  which  gives  the  circulat- 
ing fluid  a  red  color.  In  the  liver,  kidneys,  and  spleen, 
there  is  generally  more  or  less  congestion.  There  are  vari- 
ous opinions  advanced  respecting  the  conditions  of  the 
brain.  Some  modern  investigators  {AGkerman,  Dondus) 
endeavored  to  show  that  anaemia  of  the  brain  is  more  com- 
mon than  congestion.  This  idea,  however,  is  not  sustained 
by  facts,  or  accepted  by  many  in  the  profession.  The 
cerebral  vessels,  except  in  rare  cases,  are  engorged  with 
blood. 

Having  now  dwelt  on  the  physiology  of  respiration,  and 
the  pathological  changes  which  depend  upon  the  defective 
aeration  of  the  blood  and  total  cessation  of  the  respiratory 
act,  we  now  come  to  the  various  forms  of  asphyxia  and 
their  treatment. 

Stkangulation. — This  term  is  generally  applied  to  that 
variety  of  asphyxia  caused  by  external  compression ;  but 
any  mechanical  occlusion  of  the  trachea  or  larynx,  whether 
external  or  internal,  belongs  under  the  same  head. 

The  strangulation  produced  by  clasping  the  throat  tight- 
ly with  the  arm  or  hands  is  the  common  method  employed 
by  garroters.  In  suicidal  attempts,  handkerchiefs  or  ropes 
are  generally  used,  and  the  rope  is  resorted  to  in  most  civil- 
ized countries  in  judicial  strangulation.  All  cases  of  hang- 
ing, however,  do  not  terminate  by  asphyxia.     The  neck  is 

usually  broken  by  the  fall,  and  death  results  from  pressure 
10 


14G      EMERGEXCIES,  AND  HOW  TO  TREAT  THEM. 

ou  the  upper  part  of  the  spinal  cord,  and  congestion  of  the 
brain. 

The  greatest  number  of  strangulated  patients  who  come 
under  the  care  of  the  surgeon  are  those  of  attempted  sui- 
cides, and  every  stage  of  asphyxia,  from  a  slight  suffocation 
to  complete  stoppage  of  respiration,  may  be  found  among 
them. 

The  symptoms  arising  from  mechanical  occlusion  of  the 
air-passages  are  common  in  a  greater  or  less  degree  to  all 
other  varieties  of  asphyxia.  They  are  usually  so  well 
marked  as  to  preclude  a  jjossibility  of  mistake.  At  the 
same  time,  the  history  of  the  patient  should  always  be  in- 
quired into.  The  patient's  countenance  presents  an  anxious 
expression,  and  is  of  a  livid  color,  which,  in  extreme  cases, 
is  almost  black.  The  lips  are  swollen  and  somewhat  evert- 
ed, the  eyes  bloodshot  and  prominent,  the  vessels  of  the 
head  and  neck  are  enlarged  to  double  their  ordinary  size. 
There  is  an  intolerable  feeling  of  discomfort  and  oppression 
over  the  chest,  and  intense  desire  for  air.  The  respiratory 
movements  become  rapid,  but  after  a  time  they  are  slow 
and  prolonged.  There  is  a  momentary  increase  in  the  pul- 
sations of  the  heart.  As  the  asphyxia  progresses,  the  move- 
ments diminish  in  force,  until  they  are  totally  lost.  In  the 
beginning,  the  patient  suffers  from  giddiness,  ringing  in  the 
ear  (tinnitus  aurium)^  and  great  general  distress.  The  agony 
gives  way  where  asphyxia  results  from  immersion  in  water, 
and  is  succeeded  by  pleasant  visions  and  dreams.  In  some 
recorded  cases,  these  sensations  are  said  to  have  been  so  en- 
trancing as  to  cause  the  resuscitated  patient  to  curse  his 
attendants  for  bringing  him  back  to  renewed  torture.  These 
dreams  are  followed  by  insensibility ;  the  pulse  is  usually 


ASPHYXIA.  14,7 

absent,  but  tlie  action  of  the  heart  may  still  be  made  out 
witb  a  stethoscope.  So  long  as  an  impulse  is  detected, 
there  is  chance  of  recovery. 

In  asphyxia  resulting  from  violence,  there  is  often  an  ac- 
companying condition  of  syncope.  This  may  resemble  death 
to  such  an  extent  as  to  prevent  the  continuance  of  treatment. 
However,  if  the  points  of  difference  between  death  and  simple 
insensibility  are  appreciated,  there  will  be  little  difficulty. 

When  life  ceases,  the  pupils  are  dilated,  the  cornea  is 
flattened,  and  the  eyes  fixed.  There  are  congestion  of  the 
cutaneous  capillaries,  especially  in  the  most  dependent  por- 
tions of  the  body,  and  blueness  under  the  finger-nails.  (In 
true  asphyxia  this  congestion  is  not  a  sign  of  much  impor- 
tance.) All  respiratory  movements  have  ceased,  and  no 
moisture  will  appear  on  a  looking-glass  held  over  the 
mouth  or  nose.  The  pulsations  of  the  heart  cannot  be 
made  out  with  the  ear  or  stethoscope. 

Another  test  has  been  proposed  lately  by  a  French  gen- 
tleman, who  states  that,  if  a  bright  steel  needle  be  inserted 
into  tbe  dead  body,  it  will  become  tarnished ;  if  introduced 
into  the  living  body,  it  will  come  out  perfectly  clean.  If  a 
preparation  of  Calabar  bean  is  applied  to  the  eye  while  life 
is  present,  the  pupil  will  contract ;  if  death  has  taken  place, 
no  effect  will  be  produced, 

A  muscular  rigidity  {rigor  mortis)  ensues  soon  after 
death,  and  a  peculiar,  offensive  odor  is  emitted. 

Treatment. — The  treatment  of  strangulation  from  for- 
eign bodies  in  the  air-passages  has  been  considered  in  a  pre- 
vious chapter.  When  strangulation  results  from  external 
compression  of  the  throat,  a  careful  examination  should  be 
Instituted  to  ascertain  the  amount  of  local  injury.     Lacera- 


i48  EMERGENCIES,   AND   BOW   TO   TREAT   TIIEM. 

tion  or  fracture  of  tlic  larviix  or  rings  of  the  trachea  may 
cause  pieces  of  cartilage  to  protrude  on  the  internal  surface. 
Such  obstructions  must  be  removed,  in  order  to  render  the 
treatment  effectual.  All  superfluous  clothing  should  be  re- 
moved from  the  chest  and  neck,  and  the  mouth  and  throat 
cleared  of  mucus.  Artificial  respiration,  either  by  Mar- 
shall's, Hall's,  or  Sylvester's  methods,  must  then  be  tried. 
The  manner  of  employing  these  methods  is  hereafter  fully 
explained.  It  is  at  times  necessary  to  perform  tracheotomy 
{see  Tracheotomy),  and  to  fill  the  lungs  by  forcing  in  air 
with  a  bellows,  or  with  the  mouth  applied  to  the  opening. 
In  addition  to  artificial  respiration,  the  surface  of  the  body 
should  be  briskly  rubbed  to  keep  up  the  circulation,  and 
stimulants  administered  through  the  rectum.  As  in  cases 
of  hano-ino;  there  is  cono-estion  of  the  brain,  a  few  ounces 
of  blood  can  be  taken  from  the  arm  with  benefit. 

CoMPEEssiON  OF  THE  Thokacic  "Walls  produccs  suffoca- 
tion by  prev^enting  the  expansion  of  tlie  lungs  and  admis- 
sion of  air.  It  usually  occurs  from  jamming,  or  by  being 
crushed  beneath  embankments  or  masses  of  building  mate- 
rial. In  the  former  case  the  sufferer  is  usually  very  much 
frightened.  The  arms  are  thrown  involuntarily  above  the 
head,  leaving  the  chest  exposed  to  the  pressure  of  the 
crowd.  Persons  in  large  crowds  can,  with  ordinary  pre- 
cautions, protect  the  chest  by  keeping  the  arms  and  elbows 
close  to  the  side  of  the  chest,  flexing  the  forearm,  and 
bringing  it  in  front,  thus  making  the  hands  meet  in  the 
median  line.  Unless  extraordinary  pressure  is  made,  this 
method  will  allow  of  sufficient  respiratory  movement  to 
sustain  life. 

The  notorious  resurrectionist  and  murderer,  Burke,  usU' 


ASPHYXIA.  149 

ally  destroyed  Lis  victims  Ly  compressing  tlie  thoracic 
walls. 

With  this  variety  of  asphyxia  there  may  be  more  or  less 
bruising  and  laceration  of  the  chest-walls,  but  the  general 
symptoms  and  treatment  are  the  same  as  given  above. 

SurFOCATiO]sr  fbom  Inhalation  of  Gases. — The  inha- 
lation of  nitrogen  or  hydrogen  occasions  the  same  changes 
and  symptoms  as  are  witnessed  in  other  forms  of  asphyxia. 
T^itrogen  exists  in  large  quantities  in  atmospheric  air. 
When  inhaled  in  a  pure  state,  it  destroys  life  with  greater 
rapidity  than  other  gaseous  bodies. 

The  inhalation  of  sulphuretted  hydrogen,  carbonic  acid, 
carbonic  oxide,  carburetted  hydrogen,  etc.,  should  be 
treated  under  the  head  of  poisons.  As  death  in  these 
cases,  however,  is  usually  attributed  to  asphyxia,  and  as 
the  treatment  is  the  same,  they  will  be  considered  in  this 
section. 

Sulphuretted  hydrogen  is  a  product  of  the  decomposition 
of  animal  matter.  It  is  found  in  sewers,  old  drains,  and 
stagnant  pools.  The  foul  odor  of  "  rotten  eggs  "  is  due  to 
this  gas.  When  inhaled,  it  proves  rapidly  fatal.  Accord- 
ing to  Flenard,  one  part  in  a  hundred  and  fifty  of  atmos- 
pheric air  will  kill  a  horse.  Men  can  bear  larger  propor- 
tions. 

Small  quantities  of  sulphuretted  hydrogen,  inhaled  in 
a  diluted  form,  give  rise  to  nausea,  vomiting,  pains  in  the 
abdomen  and  extremities,  vertigo,  and  a  semi-paralytic 
condition  of  the  extremities.  In  large  quantities,  it  pro- 
duces rapid  insensibility,  convulsions,  and  death.  The 
body  exhales  the  characteristic  odor  of  the  gas.  After 
death  the  mouth  and  fauces  are  coated  with  a  dark-brown 


150      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

mucus.  The  muscles  and  all  the  internal  organs  are  dark- 
colored,  and  the  blood  is  fluid. 

Carbonic  acid,  or  di-oxide  of  carbon,  is  found  in  large 
quantities  in  the  bottom  of  wells,  coal-mines,  and  in  all 
dark,  damp  situations,  where  organic  matter  is  in  a  state 
of  decomposition.  In  coal-mines  it  is  usually  known  as 
"  choke-damp,"  and  death  is  often  caused  by  its  inhalation. 
This  substance  also  results  from  the  physiological  decay  of 
living  bodies. 

An  atmosphere  containing  one-tenth  of  carbonic  acid 
will  produce  death.  Its  effect  on  the  system  is  that  of  a 
narcotic  poison,  although,  when  death  results  from  its  in- 
halations, it  is  commonly  said  to  cause  suffocation,  or  as- 
phyxia. 

The  symptoms  attending  its  inhalation,  with  one  or  two 
exceptions,  resemble  those  occurring  in  ordinary  asphyxia. 
There  is  at  first  marked  loss  of  muscular  power,  with  ten- 
dency to  sleep,  and  the  countenance  assumes  a  leaden  hue. 
After  death  the  eyes  remain  bright  for  some  time,  and  sev- 
eral hours  elapse  before  rigor  mortis  sets  in. 

Charcoal-vajyor  consists  of  carbonic  acid,  carburetted 
hydrogen,  free  nitrogen,  and  atmospheric  air.  This  vapor 
is  often  used  as  a  means  of  self-murder.  In  France  it  is 
frequently  employed  for  this  purpose.  Suicides  burn  the 
charcoal  on  a  brazier,  in  a  close  room,  where  all  the  crevices 
for  the  admission  of  air  are  shut  off.  The  vapor  at  first 
creates  a  sensation  of  extreme  languor  and  general  weak- 
ness. This  is  soon  followed  by  complete  insensibility.  In 
some  of  these  cases  the  countenance  is  pale,  and  the  jaws 
are  usually  fixed.  After  death  the  heart  is  empty,  or  a 
little  black  blood  may  occupy  its  right  ventricle. 


ASPHYXIA.  151 

Coal-vapor. — The  materials  arising  from  the  ordinary 
combustion  of  coal  are  sulphurous  acid,  carbonic  acid,  sul- 
phuretted hydrogen,  and  carburetted  hydrogen.  It  is  im- 
possible to  inhale  this  vapor  under  ordinary  circumstances. 
It  possesses  such  irritating  qualities  that,  unless  a  person  is 
stupefied  with  alcohol  or  other  narcotics,  he  will  escape  be- 
fore a  sufficient  amount  is  taken  in  to  destroy  life.  Occa- 
sionally, persons  are  suffocated  in  holds  or  cabins  of  vessels 
from  this  vapor.  A  sad  instance  occurred  recently  in  New- 
York  harbor.  Five  seamen  shut  themselves  in  the  forecastle, 
where  a  brazier  of  coal  was  burning,  and  in  the  morning 
were  found  dead. 

Coal-gas. — This  substance  is  employed  for  illuminating 
purposes.  It  consists  principally  of  light  carburetted  hydro- 
gen, carbonic  oxide,  olefiant  gas,  hydrogen,  nitrogen,  etc. 
Its  odorous  principle  is  due  to  vapor  of  naphtha.  Carbonic 
oxide  is  supposed  to  be  its  principal  poisonous  ingredient. 

If  the  atmosphere  of  a  room  becomes  impregnated  with 
twelve  per  cent,  of  the  gas,  a  lighted  candle  introduced  will 
cause  an  explosion.  Accidents  arising  from  coal-gas  are 
generally  the  result  of  carelessness  or  ignorance.  Neglect- 
ing to  turn  the  gas  off,  and  leakage  in  the  pipes,  are  the 
common  causes.  The  effects  produced  by  its  inhalation  dif- 
fer from  other  varieties.  There  are  more  or  less  vertigo, 
nausea,  and  vomiting,  a  semi-paralytic  condition  of  the 
muscles,  and  convulsions  ending  often  in  death.  After  death 
the  blood  is  sometimes  of  a  light-red  color. 

Treatment. — In  all  these  varieties  of  suffocation,  inhala- 
tion of  oxygen  gas  will  bring  about  speedy  relief.  TThere 
respiration  has  ceased,  it  must  be  restored  by  artificial 
methods.     If  necessary,  oxygen  may  be  forced  into  the 


152  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

lungs  ill  the  manner  previously  mentioned.     Cold  water, 
poured  on  the  surface  of  tlie  body,  is  likewise  beneficial. 

DKOWNING. 

The  length  of  time  that  persons  can  remain  under  water, 
and  afterward  be  resuscitated,  varies  according  to  the  cir- 
cumstances attending  each  individual  case.  When  timid 
persons  become  accidentally  submerged,  they  throw  up 
the  arms,  open  the  mouth  to  shriek,  and  consequently  fill 
the  lungs  with  water  and  strangulate  at  once.  If  presence 
of  mind  is  not  lost,  the  arms  kept  under  water,  and  the  res- 
piratory movements  controlled  until  the  head  comes  above 
the  surface,  life  may  be  prolonged  a  considerable  period. 
Again,  should  the  submerged  individual  faint,  the  chances 
of  resuscitation  are  good  even  when  several  minutes  have 
been  spent  without  air.  The  fit  of  syncope  is  attended  with 
a  stoppage  of  respiration  and  of  the  heart's  action,  and,  the 
demand  for  oxygen  being  diminished,  the  system  does  not 
feel  the  loss  as  it  would  under  other  circumstances.  Occa- 
sionally, life  is  destroyed  after  an  immersion  of  one  minute, 
while  in  other  instances  persons  remain  under  water  for  two 
and  even  three  minutes  without  receiving  injur3\  Thus 
sponge  and  pearl  divers,  who  spend  a  great  part  of  their 
working-hours  under  water,  remain  deprived  of  air  for  two 
or  three  minutes  with  but  little  discomfort.  Marac  relates 
the  case  of  a  German  woman  who  was  tied  up  in  a  bag  with 
a  cock  and  cat,  and  thrown  into  the  water  as  a  punishment 
for  child-murder.  She  was  submerged  fifteen  minutes,  and, 
when  removed  from  the  bag  and  exposed  to  the  air,  imme- 
diately recovered.  Such  a  prolongation  of  life  without  air 
can  only  be  accounted  for  on  the  supposition  that  the  woman 


ASPHYXIA.  153 

fainted  on  being  immersed,  and  that  tlie  state  of  syncope 
lasted  until  she  was  brought  to  the  surface. 

A  committee  of  the  Eoyal  Chirurgical  Society,  London, 
instituted  a  series  of  experiments  to  ascertain  the  length  of 
time  animals  could  sustain  life  without  a  supply  of  oxygen. 
A  brief  statement  of  the  principal  results  will  be  of  interest. 
It  was  ascertained  that,  when  the  entrance  of  air  was  pre- 
vented by  submersion,  death  was  more  rapid  than  when 
the  trachea  was  thoroughly  closed  with  a  plug.  When  the 
trachea  was  simply  plugged,  the  respiratory  movements  con- 
tinued from  three  to  four  minutes  and  a  half,  and  the  action 
of  the  heart  was  jperceptible  from  six  to  seven  minutes  and 
a  half.  As  a  rule,  the  heart's  action  continued  two  or  three 
minutes  after  respiration  ceased.  "When  animals  were  kept 
under  water  one  minute  and  thirty  seconds,  death  followed, 
even  when  the  animal  was  taken  out  alive.  'No  efforts  were 
made  in  any  of  these  cases  to  restore  life.  If  respiration 
had  been  artificially  produced,  they  would  have  probably 
recovered.  The  striking  difference  in  the  period  of  death 
in  the  two  classes  is  explained  by  the  fact  that,  in  simple 
plugging  of  the  trachea,  sufficient  air  remained  in  the  lungs 
to  maintain  life  for  a  short  time,  while  in  the  other,  water 
found  its  way  into  the  lungs  and  displaced  the  air  which 
might  otherwise  have  been  reserved  for  aeration.  Some 
contend  that  water  does  not  enter  the  lungs  of  the  drowned, 
but  the  results  of  post-mortem  examinations  do  not  confirm 
this  statement.  Water,  sea-weed,  and  other  extraneous 
matter,  have  been  found  in  the  bronchial  tubes  in  the  major- 
ity of  cases.  It  is  true  that  at  times  there  is  not  the  slight- 
est trace  of  water.  This  circumstance  is,  however,  excep- 
tional.    The  remarkable  power  of  absorption  possessed  by 


£54  EMERGEXCIES,   AND   HOW   TO   TREAT   THEil. 

the  lungs  may  account  for  tlie  raj)id  disappearance  of  the 
liquid.  As  human  beings,  when  drowning,  alternately  sink 
below,  and  rise  again  to  the  surface  of  the  water,  occasion- 
ally giving  them  opportunity  to  obtain  a  fresh  supply  of  air, 
we  cannot  definitely  determine  tlie  maximum  of  time  they 
can  remain  under  water  and  yet  recover  afterward.  The 
experiments  quoted  are  not  proper  criteria  to  judge  by  in 
the  majority  of  drowning  cases.  When  submersion  is  con- 
tinuous, however,  five  minutes  is  the  longest  period  after 
which  life  may  be  restored.  There  is  a  peculiar  condition, 
known  as  secondary  asphyxia,  which  occurs  at  times  in  per- 
sons who  have  been  restored  by  artificial  respiration.  It 
shows  itself  generally  within  forty-eight  hours  after  respira- 
tion has  been  fully  established.  When  the  symptoms  seem 
favorable,  and  all  anxiety  removed,  the  patient  is  suddenly 
seized  with  urgent  dyspnoea,  the  chest  expands  imperfectly 
and  irregularly,  the  patient  struggles  for  breath,  and  in  a 
short  time  all  the  worst  features  of  asphyxia  return.  Death 
soon  supervenes,  unless  immediate  relief  is  afforded  by  arti- 
ficial respiration.  The  cause  of  this  change  is  not  well  un- 
derstood. It  is  probably  due  to  congestion  of  the  lungs, 
induced  by  some  active  movements  on  the  part  of  the  pa- 
tient. The  exercise  sends  more  blood  to  these  organs  than 
they,  in  their  weakened  condition,  can  provide  for.  Exces- 
sive and  laborious  respiration  immediately  follows.  The  ap- 
pearances presented  in  asphyxia  resulting  from  immersion 
vary  somewhat  from  other  kinds.  The  livid  discoloration 
of  the  face  and  fulness  of  the  blood-vessels  are  not  so  dis- 
tinctly marked.  There  are  more  general  pallor  and  coldness 
of  the  surface.  Rigor  mortis  or  'post-mortem  contractions 
of  the  muscles  appear  very  soon  after  death. 


ASPHYXIA.  155 

Treatment. — There  are  four  special  requisites  ia  tlie 
treatment  of  drowned  persons :  1.  Artificial  resjpiration  /  2. 
Warmth',  3.  Friction '^  4.  Stimulation.  All  these  are 
employed  togetlier,  but  the  first  is  generally  relied  on. 
Strip  the  patient  of  clothing,  and  envelop  the  Lody  as  fai 
as  possible  in  warm  blantets.  Then  clear  the  mouth  and 
throat  of  water,  mucus,  or  other  substance  which  might  pre- 
vent the  ingress  of  aii\* 

To  do  this  perfectly,  cover  the  index-finger  closely  with 
a  handkerchief,  and  carry  it  in  as  far  as  possible,  and  sweep 
it  around  the  pharynx  and  upper  part  of  the  larynx.  The 
cloth  takes  up  more  of  the  moisture  than  the  finger  alone 
would.  The  tongue  is  now  drawn  out  as  far  as  possible. 
Unless  the  organ  is  pulled  forward  with  considerable  degree 
of  force,  the  aryteno-epiglottidean  folds  at  the  upper  border 
of  the  larynx  will  close  the  aperture  sufficiently  to  inter- 
fere with  the  admission  of  air.  This  is  a  point  of  consider- 
able importance  in  all  cases  where  artificial  respiration  is 
resorted  to,  and  cannot  be  too  strongly  insisted  upon.  A 
forceps  attached  to  the  extremity  of  the  tongue,  or  a  towel 
wrapped  around  its  end,  and  grasped  with  the  thumb  and 
forefinger,  will  make  traction  easy.  Having  cleansed  the 
air-passages,  we  try  some  of  the  methods  of  artificial  respii'a- 
tion.  "When  the  immersion  has  been  short,  and  the  patient 
only  partially  asphyxiated,  simple  compression  of  the  lower 
half  of  the  thorax  and  upper  part  of  the  abdomen  will 
answer.  The  hands  are  applied  on  eacli  side  of  the  chest- 
walls,  the  fingers  reaching  as  high  as  the  nipple,  and  firm 

*  Some  advise  suspension  of  the  drowned  person  by  the  limbs,  in  order  to 
facilitate  the  escape  of  water  from  the  lungs ;  but  this  is  an  unnecessary  pro 
cedure. 


156  EMERGENCIES,  AND  HOW  TO   TREAT  THEM. 

pressure  made  to  diminish  the  cavity  of  the  chest.  The 
hands  are  then  lifted  for  a  few  second:?,  and  the  parts 
allowed  to  resume  their  natural  position. 

This  is  done  rapidly  and  continuously  until  all  danger  has 
passed.  Diminishing  the  thoracic  cavity  by  pressure  forces 
out  some  of  the  foul  air  from  the  lungs,  and  with  the  sub- 
sequent expansion  a  certain  amount  of  fresh  air  passes  in. 
This  interchange  gives  more  oxygen  to  the  blood,  and 
relieves  it  of  carbonic  acid,  stimulates  the  circulation, 
and  through  it  the  nervo-muscular  apparatus,  and  finally 
restores  all  the  functions  of  life.  In  severe  cases,  either 
Marshall  Hall's  or  Sylvester's  method  of  artificial  respira- 
tion is  to  be  preferred.  The  latter  is  said  to  be  superior,  as 
it  enables  more  air  to  pass  out  of  and  enter  the  chest.  The 
preliminary  steps,  such  as  clearing  the  throat  and  drawing 
out  the  tongue,  are  the  same.  In  Marshall  Hall's  method 
the  patient  is  placed  on  the  side,  with  the  arm  toward  the 
posterior  plane  of  the  body.  The  body  is  then  rolled  slowly 
over  on  the  face,  while  the  hands  of  the  surgeon  at  the  same 
time  are  pressed  firmly  on  the  back  and  sides  of  the  chest, 
diminishing  its  cavity.  When  this  movement  is  completed 
the  patient  is  turned  on  his  back,  and  the  chest-walls  re- 
sume their  original  position ;  these  movements  are  to  be 
kept  up  until  natural  respiration  is  resumed.  The  principal 
efiect  to  be  produced  in  all  cases  is  a  renewal  of  the  air  in 
the  lungs.  In  Sylvester's  method  the  patient  is  placed  in 
the  recumbent  position,  with  the  head  and  chest  somewhat 
raised.  The  operator  stands  at  the  head  of  the  patient  and 
grasps  both  arms  midway  between  the  elbow  and  wrist- 
joint,  moving  them  gradually  to  a  vertical  position  so  as  to 
make  them  nearly  meet  above  the  head.     They  are  held  in 


ASPHYXIA.  157 

this  position  for  a  moment,  and  then  slowly  returned  to  the 
Bides.  At  the  termination  of  the  second  movement,  pressure 
is  made  with  the  arms  on  the  sides  of  the  thoracic  walls. 
These  movements  are  continued  as  long  as  the  asphyxia 
remains.  Raising  the  arms  in  this  manner  elevates  the 
ribs,  and  allows  comparatively  a  large  quantity  of  air  to 
enter,  while  relaxation  causes  them  to  resume  their  normal 
relations.  Conjointly  with  all  varieties  of  artificial  respira- 
tion, the  patient's  limbs  should  be  briskly  rubbed  by  an 
assistant,  and  brandy  and  ammonia  sbould  be  administered 
through  the  mouth  or  rectum.  Hot  bottles  and  blankets 
are  to  be  applied  to  the  extremities  before  and  after  the 
patient  has  recovered.  Heat,  by  means  of  hot-air  baths,  is 
sometimes  useful.  Ammonia,  in  the  form  of  vapor  or  in 
solution,  may  be  applied  to  the  nostrils.  Should  ordinary 
artificial  respiration  fail  to  revive  the  patient,  pure  oxygen 
may  be  forced  into  the  lungs.  This  may  be  done  by  cutting 
a  hole  in  the  trachea,  inserting  a  tube,  and  forcing  tlie  gas 
through  it.  The  ordinary  elastic  bag  employed  for  inhala- 
tion of  oxygen,  if  pressed  with  moderate  force,  will  send  in 
enough  gas  to  distend  the  lungs.  If  the  gas  is  not  at  hand, 
the  nozzle  of  a  bellows  may  be  attached  to  the  tracliea-tube, 
and  the  necessary  expansion  accomplished  with  atmospheric 
air. 

Injuries  to  the  Spinai.  Coed,  above  the  origin  of  the 
phrenic  and  intercostal  nerves,  paralyze  the  muscles  of 
respiration  and  produce  death  by  asphyxia.  Poisonous 
doses  of  nux-vomica  or  its  alkaloids  cause  spasm  of  the 
same  set  of  muscles,  and  terminate  life  in  like  manner. 


CHAPTER  XIII. 

SUNSTROKE. 

Syiionymcs. — Heat  Apoplexy — Insolation — Sun-Fever. 

"We  have  records  of  sunstroke  from  the  earliest  histori- 
cal times.  It  is  fully  described  by  ancient  medical  writers. 
About  the  first  cases  mentioned  are  the  following,  from 
biblical  history : 

"  Manassas  was  her  husband,  who  died  in  the  early  har 
vest :  for,  as  he  stood  among  them  and  bound  sheaves  in 
the  field,  the  heat  came  upon  his  head,  and  he  fell  on  his 
bed,  and  died  in  the  city  of  Bethuliah."  The  second  in- 
stance relates  to  the  son  of  the  Shunammite  woman,  who 
was  restored  to  life  by  the  prophet  Elisha:  "And  when  the 
child  was  grown,  it  fell  on  a  day  that  he  went  out  with  his 
father  to  the  reapers.  And  he  said  unto  his  father,  '  3Iy 
head,  my  head.''  And  when,  he  had  taken  him  and  brought 
him  to  his  mother,  he  sat  on  her  knees  till  noon,  and  ther 
died." 

Sunstroke  is  not  confined  to  tropical  regions ;  iNew  Tork 
and  other  Northern  cities  sufiPer  from  its  yearly  visitations. 
At  certain  seasons  the  number  of  cases,  in  proportion  to 
the  population,  far  exceeds  that  of  the  more  tropical  towns. 
In  jSTew  Tork,  especially,  the  mortality  has  been  verv  great. 


SUNSTROKE.  159 

During  the  summers  of  18G6  and  1868  an  immense  num- 
ber of  cases  were  recorded. 

Visitors  to  the  tropics  from  the  colder  regions,  who  are 
unaccustomed  to  a  high  temperature,  are  particularly  sus- 
ceptible ;  while  the  natives,  who  live  constantly  exposed  to 
the  heat,  are  comparatively  safe. 

Sunstroke  does  not  depend  upon  a  short  exposure  to  the 
direct  rays  of  the  sun ;  the  exposure  must  have  been  con- 
tinued for  a  day  or  two ;  nor  does  it  necessarily  arise  from 
solar  heat.  Prolonged  confinement  in  the  heated  atmos- 
phere of  a  building  may  likewise  produce  it. 

Dr.  Maclean  *  speaks  of  thirteen  cases  which  occurred 
under  Mr.  Longmore,  in  the  barracks  at  Burrackpoor,  India, 
while  only  three  arose  from  outside  exposure.  The  same 
thing  has  been  witnessed  on  crowded  vessels,  in  laundries, 
and  sugar-refineries.  I  recall  three  fatal  cases  which  were 
admitted  to  Bellevue,  of  persons  who  were  prostrated  while 
at  work  in  a  sugar-refinery.  Dr.  Swift  gives  the  history  of 
twelve  persons  who,  while  at  work  in  a  large  laundry  in 
this  city,  were  similarly  afiected.  Some  of  these  patients 
may  have  been  exposed  to  the  solar  rays,  but  the  majority 
were  at  work  in-doors. 

About  the  third  or  fourth  day  from  the  commencement 
of  a  heated  term,  sunstrokes  usually  appear.  The  sufierers 
in  most  cases  are  exposed  to  the  heat  for  some  days  pre- 
ceding the  attack. 

In  the  summer  of  1866  the  majority  of  sunstroke  cases 
— generally  laboring-men — were  brought  to  Bellevue  Hos- 
pital in  the  morning  or  early  in  the  day. 

*  Reynolds's  Practice,  article  Sunstroke,  p.  156. 


160  EMERGENCIES,  AST)  HOW  TO  TREAT  THEM. 

Persons  of  intemperate  liabits  and  debilitated  systems 
are  most  liable  to  attack.  Any  thing  tending  to  lower  the 
vitality  of  the  system  predisposes  to  the  atlection.  Wear- 
ing heavy,  dark  clothing,  or  compressing  the  chest,  is  also 
unsafe.  The  close-fitting  regulation  uniform  and  equip- 
ments worn  by  the  British  soldiers  in  India  swelled  the 
bills  of  mortality  from  sunstrokes  when  that  country  was 
first  occupied.  Better  sanitary  ideas  of  soldiers'  dress 
have  been  developed  within  the  past  few  years,  and  the 
death-list  has  consequently  diminished. 

Sunstrokes  may  be  classed  under  two  heads :  1.  Those 
in  which  the  nerve-centres  are  principally  involved,  or  the 
cerebro-spinal  variety  of  Morehead ;  2.  The  varieties  which 
are  characterized  by  exhaustion.  Death  in  the  former  case 
results  from  coma  j  in  the  latter,  from  syncope.  In  some 
forms  death  is  ascribed  to  asphyxia,  or  apnoea. 

Persons  of  full  habit  addicted  to  the  use  of  spirituous 
liquors  are  generally  victims  of  the  cerebro-spinal  variety. 
Hard-working  individuals  are  more  liable  to  the  cardiac 
form. 

In  typical  cases  of  sunstroke  the  symptoms  may  be  di- 
vided into  premonitory  and  immediate.  The  premonitory 
symptoms  are  not  always  evident.  The  patient  complains 
of  headache  and  a  burning  sensation  about  the  head,  and 
during  the  night  is  restless  and  wakeful.  The  skin  is  dry 
and  uncomfortably  hot,  and  there  is  frequent  desire  to 
evacuate  the  bladder.  The  face  is  flushed,  and  eyes  con- 
gested ;  the  bowels  are  usually  constipated.  A  person  pre- 
senting these  symptoms,  who,  nevertheless,  continues  to 
work  under  the  hot  sun,  or  in  an  overheated  building,  will 
be  suddenly   seized  with  vertigo,   intense  headache,  and 


SUNSTROKE.  101 

dimness  of  vision.  His  limbs  refuse  to  support  him,  and 
he  soon  falls  to  the  ground.  Insensibility  sets  in ;  the 
breathing  becomes  stertorous,  pupils  contract,  and  the  skin 
is  intensely  hot.  The  temperature  of  the  body,  ascertained 
by  a  thermometer  in  the  axilla,  varies  from  100  to  107,  in 
rare  cases  reaching  109.  The  pulse  is  rapid,  and  often  full ; 
as  the  case  progresses  toward  a  final  termination,  it  becomes 
weaker  and  irregular,  but  still  very  rapid.  The  coma  may 
be  either  partial  or  complete,  and  occasionally  there  are 
convulsions.  The  bowels  are  sometimes  relaxed,  and  vom- 
iting is  not  infrequent. 

There  are  various  grades  or  manifestations  of  sunstroke. 
Some  who  come  under  the  physician's  care  complain  of  in- 
tense weakness,  and  pain  in  the  head.  Others  are  stupid 
and  wandering,  while  complete  insensibility  accompanies 
the  great  majority  of  cases.  In  some  the  general  malaise 
and  warning  symptoms  precede  the  insensibility  for  several 
days ;  others  are  stricken  down  in  a  moment,  without  pre- 
vious uncomfortable  sensations. 

In  those  varieties  of  sunstroke  characterized  by  exhaus- 
tion or  syncope  the  patients  are  more  apt  to  die  suddenly 
without  special  premonitory  troubles.  In  such  cases  the 
countenance  is  paler  than  in  the  cerebro-spinal  variety.  The 
respiration  is  sighing  or  gasping  instead  of  being  stertorous. 
The  pulse  is  generally  rapid,  compressible,  and  irregular. 
The  pupils  may  be  dilated,  the  heat  of  the  skin  is  not  ex- 
treme; sometimes  there  is  a  combination  of  the  cardiac  and 
cerebro-spinal  varieties. 

The  reason  why  consciousness  is  lost,  from  exposure  to 
extreme  heat,  is  not  fully  understood ;  overheating  of  the 
blood  is  said  by  some  authorities  to  call  for  excessive  action 
11 


1(30      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

iu  the  nerve-centres,  which  rapidly  exhaust  their  force  and 
power. 

Maclean  and  others  regard  the  heated  blood  as  produ- 
cing great  depression  of  the  nervous  system,  and  thus  pre- 
venting it  from  performing  its  functions.  The  latter 
theory  seems  the  most  plausible. 

Even  if  we  accept  this  view,  there  are  changes  in  the 
nerve-fibres  and  cells  which  we  have  as  yet  been  unable  to 
recognize  or  fully  understand.  These  changes,  in  many 
cases,  make  recovery  from  sunstroke  more  to  be  dreaded 
even  than  death  itself.  They  give  rise  to  the  varied  sequelae 
of  sunstroke,  such  as  amaurosis,  obstinate  and  distressing 
headache,  and  impairment  of  the  intellect. 

Insanity  in  its  varied  forms  is  a  common  sequence.  In 
some  instances,  the  brain  is  found  to  be  softened  after  death, 
in  others  there  is  no  special  lesion  perceptible. 

On  post-mortem  examination  the  brain  and  its  mem- 
branes are  usually  found  to  be  congested.  In  persons  who 
die  from  exhaustion  this  feature  is  less  marked.  The  great 
mass  of  cases,  however,  show  this  change.  Out  of  twenty- 
two  jpost-mortems  which  I  made  in  Bellevue,  twenty  pre- 
sented cerebral  congestion.  All  had  marked  congestion  of 
the  lungs.  Two  of  them  showed  evidences  of  inflammation 
in  the  mucous  membrane  lining  the  stomach  and  intestines. 
Before  death  they  had  violent  attacks  of  vomiting  and 
purging.  Congestion  of  the  lungs  is  almost  always  present. 
The  right  side  of  the  heart  is  distended  with  blood  which  is 
entirely  fluid,  and  without  tendency  to  coagulate.  Decom- 
position proceeds  rapidly  after  death  from  sunstroke. 

Treatment. — It  was  considered  imperative  at  one  time 
to  abstract  blood  in  all  cases  of  sunstroke.    Modern  enliirht- 


SUNSTROKE.  Kjy 

enment  Las  excluded  tliis  therapeutical  agent.  Depleting 
measures  of  every  kind  are  now  considered  injurious. 

The  patient  should  be  removed  at  once  to  a  cool  room, 
and  placed  in  a  recumbent  position  near  an  open  window. 
The  clothes  are  then  stripped  off',  and  a  stream  of  water 
poured  over  the  bodj.  The  vessel  containing  the  liquid  is 
to  be  held  about  four  or  five  feet  above  the  patient,  in  order 
that  he  may  receive  the  benefit  of  the  shock.  The  stream 
of  water  should  at  first  be  directed  on  the  head,  then  on  the 
chest  and  abdomen,  and  finally  on  the  extremities,  and  thus 
alternating  from  one  part  to  another,  until  consciousness 
returns.  Ice  rubbed  over  the  body  is  liked  by  some ;  the 
cold  douche  is,  however,  preferable. 

When  the  dyspnoea  is  marked,  a  few  dry  cups  placed  on 
the  thorax  in  front  and  behind  will  be  of  service. 

Internal  medication  is  useful  in  all  cases.  Among  the 
numerous  drugs  employed,  bromide  of  potassium  has  been 
found  most  efficient.  The  best  results  were  obtained  from 
its  use  in  Bellevue  Hospital,  in  the  years  1866  and  1868, 
This  drug  may  be  administered  in  all  stages  of  the  affection. 
"When  the  patient  is  unable  to  swallow,  it  can  be  given  by 
injection,  always  remembering  to  increase  the  dose  one- 
quarter  more  than  when  given  by  mouth.  In  mild  cases 
from  five  to  ten  grains  may  be  given,  at  intervals  of  from 
half  an  hour  to  one  hour,  until  the  grave  symptoms  disap- 
pear. In  several  forms  from  ten  to  thirty  grains  may  be 
administered  every  half-hour ;  when  the  pulse  becomes  weak 
or  intermittent,  stimulants  are  needed.  Stimulation  should 
be  resorted  to  in  all  cases  where  exhaustion  is  the  prominent 
feature.  Brandy-and-milk,  or  brandy  with  ammonia,  must 
be  introduced  into  the  stomach  or  rectum. 


164  EMERGENCIES,  AND   HOW  TO  TREAT  THEM. 

The  cold  douche  must  be  sparingly  employed,  or  alto- 
gether dispensed  with  in  this  latter  class  of  cases.  If  the 
skin  is  cold,  it  will  do  no  good  whatever. 

After  consciousness  has  returned,  mustard-plasters  or 
blisters  are  to  be  applied  to  the  back  of  the  neck  or  be- 
hind the  ears.  Tlie  bromide  need  not  be  discontinued  for 
one  or  two  weeks. 

As  soon  as  convenient,  the  patient  should  be  sent  to  a 
cool  district  in  the  country,  and  kept  free  from  all  sources 
of  excitement.  The  brain  must  rest  from  all  work.  Exer- 
cise in  the  open  air  and  nourishing  diet  are  essential ;  regu- 
lar habits  must  be  rigidly  enforced.  A  continuance  of  this 
treatment  for  several  months  prevents  or  at  least  lessens  the 
danger  from  nervous  affections  which  follow  sunstroke. 


CHAPTEK  XIV. 

D  TSPNCEA. 

Dyspnoea  from  Asthma — Croup — Congestion  of  the  Lungs — Cardiac  Diseac* 
— Pulmonary  CEdema — Puhnonary  Apoplexy,  etc. 

Shoetness  of  breath  or  difficult  respiration  arises  from 
defective  aeration  of  the  blood.  Any  condition  which 
diminishes  the  amount  of  oxygen  sent  to  the  tissues,  or 
creates  a  demand  for  more  than  the  lungs  in  ordinary  respi- 
ration can  furnish,  will  occasion  dyspnoea.  Over-exertion 
produces  the  simplest  illustration  of  the  manner  of  its  pro- 
duction. Yiolent  muscular  movements  quicken  the  cardiac 
impulses,  and  a  larger  amount  of  blood  is  sent  to  the  lungs 
as  well  as  to  other  organs.  There  follows  a  demand  for 
more  oxygen,  and  the  respiratory  movements  are  increased 
to  make  up  by  rapidity  of  inhalation  the  diminished  quan- 
tity of  that  element  in  the  blood. 

In  the  category  of  diseases  characterized  by  dyspncea 
are  included  asthma,  croup,  congestion  of  the  lungs,  cardiac 
affections,  pneumonia,  bronchitis,  pulmonary  oedema,  pul- 
mon  ary  apoplexy,  and  cedema  glottidis.  The  dyspnoea  which 
is  caused  by  mechanical  obstruction  or  occlusion  of  the  air- 
passages  is  considered  in  another  chapter. 

Asthma. — In  this  disease  there  is  a  spasmodic  contrac- 
tion of  the  muscular  fibres  of  the  smaller  bronchial  tubes, 


106      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

and  a  consequent  diminished  calibre  of  these  tubes,  which 
prevents  the  free  ingress  of  air.  Asthma  exhibits  a  pref- 
erence for  certain  localities  and  seasons  of  the  year.  It 
may  occur  at  any  season,  but  prevails  specially  in  the 
autumn.  It  is  said  to  be  caused  in  some  instances  by  the 
inhalation  of  new-mown  hay,  ipecac,  coal-dust,  and  other 
substances.  Inflammation  of  the  bronchial  tubes  also  ex- 
cites it.  It  is  not  an  unfrequent  accompaniment  of  emphy- 
sema. 

The  paroxysms  usually  develop  suddenly.  The  patient 
struggles  for  breath,  and  runs  to  the  open  window.  The 
respirations  are  not  quickened.  A  wheezing  noise  is  heard 
with  each  respiratory  movement.  The  voice  is  low  and 
husky.  The  face  is  congested,  the  lips  blue,  and  the  eyes 
prominent.  A  cold  perspiration  appears  on  the  surface. 
The  pulse  is  small,  and  in  some  cases  very  rapid.  There  is 
inability  to  maintain  the  recumbent  position.  The  patient 
usually  sits  bent  forward  and  resting  on  his  knees,  bringing 
every  auxiliary  muscle  of  respiration  into  use  to  obtain  air. 
On  auscultation,  loud  sibilant  and  sonorous  rales  are  heard 
over  both  lungs.  The  attack  usually  lasts  from  half  an 
hour  to  four  or  five  hours ;  but  it  may  continue  with  vary- 
ing degrees  of  severity  for  two  or  three  days. 

The  absence  of  oedema,  valvular  lesions,  febrile  excite- 
ment, etc.,  and  the  comparative  good  health  between  the 
paroxysms,  are  suflScient  to  distinguish  the  disease. 

Treatment. — Pure  oxygen  has  lately  been  employed  with 
considerable  benefit  in  this  disease.  Five  or  six  gallons 
should  be  inhaled  every  fifteen  or  twenty  minutes  until 
relief  is  experienced.  Even  where  it  does  not  comj^letely 
subdue  the  paroxysm,  it  will  at  least  diminish  the  distress. 


DYSPNOEA.  107 

Chloroform,  ether,  and  other  anaesthetics,  may  also  be 
given  with  advantage.  There  are  some  cases  which  can 
only  he  relieved  by  these  medicines. 

The  majority  of  practitioners  employ  simple  antispas- 
modics, such  as  stramonium,  belladonna,  or  lobelia.  The 
former  drug  may  be  given  in  two-grain  doses  every  half- 
hour,  or  the  leaves  may  be  smoked  in  a  pipe,  or  in  the  form 
of  cigarettes,  until  relief  is  obtained.  Hoffman's  anodyne 
may  be  used  in  conjunction  with  inhalation  of  steam.  A 
basin  of  hot  water  is  held  under  the  patient's  head,  the  ano- 
dyne is  poured  slowly  in,  and  the  ethereal  vapor  mixes  with 
the  steam,  and  is  inhaled.  A  blanket  thrown  over  the 
head  of  the  patient  prevents  the  steam  from  escaping. 
Belladonna  in  quarter-grain  doses  of  the  extract  relieves 
certain  varieties  of  asthma  with  great  rapidity.  Emetic 
doses  of  lobelia,  eupatorium,  or  ipecac,  are  recommended  by 
some. 

Ckoup. — There  are  two  principal  varieties  of  this  disease, 
viz.,  membranous  and  spasmodic.  The  first  is  an  inflam- 
matory affection,  attended  with  fibrinous  exudation,  and  is 
usually  fatal.  In  the  second  there  is  a  spasmodic  contrac- 
tion of  the  muscles  which  govern  the  vocal  cords.  It  may 
appear  with  or  without  catarrh  of  the  larynx,  and  is  rarely 
if  ever  fatal.  As  the  spasmodic  variety  is  more  rapidly 
developed,  and  as  a  rule  unattended  by  premonitory  symp- 
toms, it  may  properly  be  considered  a  case  of  emergency,  and 
discussed  in  this  connection. 

The  spasm  of  the  vocal  cords  which  occurs  in  spas]nodic 
croup  may  arise  from  the  reflex  irritation  of  worms  in  the 
alimentary  canal,  from  teething,  or  from  a  cold  or  catarrh. 
The  attack  comes  on  in  the  nisht.     The  child  wakes  from 


168      EMERGENCIES,  AND  UOW  TO  TREAT  THEM. 

its  sleep  with  a  loud,  heavy,  croupous  cough,  husky  voice, 
and  intense  dyspnoea.  The  face  becomes  dusky  and  livid, 
and  the  extremities  are  cold.  In  a  short  time  the  Bj)asm 
relaxes,  and  the  child  resumes  its  natural  breathing ;  but 
the  hard  cough  and  changed  voice  remain  longer.  If  the 
attack  be  connected  with  catarrh,  the  hoarseness  is  more 
likely  to  continue,  and  the  paroxysms  will  recur  at  various 
intervals  during  the  night.  It  is  differentiated  from  mem- 
branous croup  by  the  absence  of  exudation  on  the  tonsils, 
constitutional  and  local  signs  of  inflammation,  and  also  by 
the  fact  that  in  spasmodic  croup  there  is  complete  relief 
between  the  paroxysms.  In  the  membranous  or  true 
croup  the  dyspnoea  continues  or  increases  as  the  disease 
advances. 

Treatment. — An  emetic  composed  of  a  drachm  or  two 
of  the  wine  of  ipecac,  or  four  or  live  grains  of  the  powder, 
should  be  administered  without  delay.  The  child  sliould 
then  be  immersed  in  a  hot  bath  for  five  or  ten  minutes. 
"When  taken  out,  warm  blankets  should  be  wrapped  around 
the  body,  and  hot  flannels  or  hot  hop-poultices  applied  to 
the  throat.  To  prevent  a  recurrence  of  the  paroxysm,  all 
sources  of  irritation  should  be  removed,  and  the  general 
health  sustained  by  attention  to  diet,  nutritious  food,  good 
air  and  exercise.  If  there  be  a  strong  predisposition  to 
these  attacks,  small  doses  of  bromide  of  potassium,  bella- 
donna, valerian,  etc.,  may  be  given  with  salutary  effect. 

Membranous  croup  is  treated  by  inhalation  of  steam, 
oxygen,  and  internal  administration  of  iodide  of  potassium  ; 
tracheotomy  is  sometimes  performed.     Recovery  is  rare. 

CoNGESTiox  OF  THE  LuNGS. — Dyspngea  which  occurs 
from  engorgement  of  the  pulmonary  capillaries  is  rarely  aa 


DYSPN(EA.  169 

eudden  in  its  origin  as  that  wliicli  arises  from  croup  or 
asthma.  Congestion  is  due  to  a  variety  of  causes.  It  is  an 
accompaniment  of  pneumonia  and  bronchitis,  and  is  a  fatal 
element  in  the  latter  stages  of  cardiac  disease.  Patients 
with  valvular  lesions  or  other  organic  affection  of  the  heart 
are  after  unusual  exertion  liable  to  congestion.  The  debili- 
tated heart  beats  with  greater  rapidity  and  violence,  and 
the  lungs,  already  overloaded  with  blood,  become  rapidly 
engorged.  The  respiratory  movements  are  almost  doubled 
in  endeavoring  to  introduce  the  necessary  amount  of 
oxygen. 

The  patient  sits  up  in  bed,  moving  the  head  from  side 
to  side,  and  gasping  for  breath.  There  is  an  expression  of 
great  anxiety,  and  the  face  is  bathed  in  cold  perspiration, 
and  marked  by  the  characteristic  cyanosis.  The  pulse  is 
irregular,  rapid,  and  intermittent.  Sometimes  the  over- 
loaded blood-vessels  relieve  themselves  by  rupture,  and  pour 
out  blood  into  the  parenchyma  of  the  lung,  and  into  the  bron- 
chial tubes.  If  the  extravasation  is  great,  a  fatal  termina- 
tion is  reached  in  a  short  time  ;  a  small  haemorrhage  is  of 
little  consequence. 

Treatment. — ^Medicines  which  diminish  the  frequency 
of  the  heart's  action  are  indispensable.  Digitalis  is  the 
best  remedy  we  possess  for  the  purpose.  Aconite  and  vera- 
trum  viride  are  preferred  by  some.  Digitalis  may  be  given 
in  powder,  tincture,  or  extract.  The  tincture  is  the  most 
reliable  preparation.  It  may  be  given  in  five-drop  doses 
every  half-hour  until  the  patient  is  relieved.  "With  the  in- 
ternal medication  the  application  of  a  dozen  dry  cups  to  the 
chest  is  called  for.  If  the  patient  is  not  very  much  debili- 
tated,  a  few  wet  cups  may  be   applied.     Inhalations  of 


170      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

oxygen  gas  are  also  beneficial.  The  subsequent  treatment 
consists  in  restraining  the  patient  from  all  active  exercise, 
and  keeping  the  action  of  the  heart  Avithin  proper  limits. 
Every  source  of  mental  excitement  must  be  avoided.  Ton- 
ics, good  diet,  and  fresh  air,  are  always  necessary. 

Congestion  dependent  upon  pneumonia  or  bronchitis  is 
relieved  by  cathartics,  counter-irritation  by  means  of  blisters, 
abstraction  of  blood  with  wet  cups,  and  promoting  diapho- 
resis by  small  doses  of  antimony  or  ipecac. 

PuLMONAET  (Edema  is  iuduccd  by  conditions  which  give 
rise  to  oedema  in  other  parts  of  the  body.  It  occurs  in 
cardiac  disease,  and  in  degeneration  of  the  kidneys.  The 
serum  is  pouied  out  from  the  distended  vessels  into  the  air- 
cells  and  areolar  tissue  of  the  lungs.  Both  lungs  usually 
are  affected.  In  the  recumbent  position  the  serum  gravi- 
tates to  the  posterior  portion  of  these  organs.  The  exuda- 
tion usually  takes  place  gradually,  but  it  may  be  poured 
out  so  rapidly  as  to  destroy  life  in  a  few  moments. 

Urgent  dyspnoea  marks  its  occurrence.  The  patient's 
face  and  limbs  may  be  swollen  from  oedema,  or  other  signs 
of  Bright's  disease,  or  cardiac  diseases,  may  be  present.  The 
immediate  symptoms  are  the  same  as  those  arising  from 
congestion.  A  positive  diagnosis,  however,  cannot  be  made 
without  the  physical  signs.  There  is  dulness  posteriorly 
over  the  lower  lobes  of  both  lungs,  which  was  not  preceded 
by  inflammatory  symptoms.  The  respiratory  murmur  is 
diminished  in  intensity,  and  small  sub-crepitant  or  crepitant 
rales  of  a  liquid  character  are  heard  over  the  same  locations. 
There  is  also  a  cough,  with  a  frothy,  limpid  expectoration. 

Treatment. — The  chief  indication  is  to  diminish  the 
quantity  of  serum  in  the  lung-tissue,  and  this  is  done  by 


DYSPN(EA.  171 

abstracting  serum  from  the  Llood  through  the  skin  and 
bowels.  If  the  debility  is  not  too  great,  small  doses  of  ela- 
terium  or  croton-oil  may  be  given,  to  produce  free  evacua- 
tions from  the  intestines.  Hot-air  baths,  hot  bottles  and 
blankets  are  useful  in  promoting  perspiration.  Acetate  of 
potash  may  be  given  to  act  on  the  kidneys  and  increase 
the  flow  of  urine.  Wet  cups,  applied  to  the  chest-  walls 
posteriorly,  are  also  beneficial. 

Dyspnoea,  arising  from  oedema  glottidis  and  mechanical 
occlusion  of  the  air-passages,  is  considered  in  other  chapters. 


CHAPTEH  XY. 

CE  D  E  If  A      G  L  0  T  T  J  DI  S. 

In  tliis  affection  there  is  an  exudation  of  serum,  under- 
neath the  raucous  membrane  lining  the  upper  portion  of  the 
larynx.  Above  the  vocal  cords  this  membrane  is  loosely 
attached  to  the  underlying  structures,  and  is  more  liable 
than  other  parts  of  the  organ  to  be  the  seat  of  serous  exu- 
dation. 

The  greatest  amount  of  oedema  will  be  found  in  the  ary- 
teiio-epiglottidean  folds,  situated  at  the  sides  of  the  superior 
aperture  of  the  larynx,  and  at  the  base  of  the  epiglottis. 
The  aryteno-epiglottidean  folds  are  reduplications  of  mucous 
membrane  which  loosely  cover  the  cuneiform  cartilages. 
Large,  irregular  pouches,  which  are  here  developed  by  the 
infiltration  of  serum,  hang  over  the  laryngeal  aperture. 
These  bags  are  forced  in  with  each  inspiration,  making  the 
opening  still  smaller,  and  seriously  obstnicting  the  ingress 
of  air. 

(Ede;ma  Glottidis  occurs  more  frequently  in  adults  than 
in  children  ;  the  reasons  for  this  are — 1.  That  in  early  life  the 
mucous  membrane  of  the  larynx  adheres  more  intimately  to 
the  adjacent  tissues.  An  exudation  of  any  kind  from  the 
blood-vessels  would  therefore  appear  on  the  free  surface  of 
the  membrane,  and  not  on  its  attached  portion ;   2.  The 


(EDEMA  GLOTTIDIS.  173 

diseases  wliich  occasion  oedema  are  more  common  in  ad- 
vanced life  than  in  youth. 

The  affection  depends  on  conditions  which  give  rise 
to  exudations  of  serum  in  other  parts  of  the  body,  such  as 
obstructions  to  the  circulation ;  inflammations,  lack  of 
tonicity  in  the  vascular  walls,  or  a  watery  condition  of 
the  blood.  It  is  not  unusual  during  the  progress  of  all 
chronic  kidney-diseases,  erysipelas,  small-pox,  continued 
fevers,  etc.  It  is  in  most  cases  an  attendant  of  acute  and 
chronic  inflammation  of  the  larynx  ;  it  may  arise,  however, 
as  an  independent  affection.  When  it  proceeds  from 
inflammation,  Yirchow  applies  to  it  the  term  collateral 
oedema.  The  inflammatory  stasis  offers  an  obstruction  to 
the  circulation  in  the  diseased  part,  increases  the  pressure 
in  the  blood-vessels,  so  that  the  watery  portions  exude  in 
the  areolar  tissue.  Exceptionally,  it  has  been  known  to 
occur  in  thoracic  aneurism,  and  in  quinsy  sore-throat,  and 
pharyngitis  from  extension  of  the  inflammation.  "Whether 
occurring  alone,  or  in  connection  with  local  or  constitu- 
tional diseases,  the  symptoms  of  oedema  glottidis  are  dis- 
tinctly marked.  The  patient  complains  of  great  difficulty  in 
breathing,  which  seems  to  proceed  from  an  obstruction 
located  in  the  throat,  and  he  coughs  violently  in  order  to 
eject  it.  If  the  epiglottis  be  involved  to  any  extent,  there 
will  be  pain  in  the  act  of  swallowing.  The  difficult  respira- 
tion rapidly  increases.  Extreme  distress  is  apparent.  The 
patient  grasps  the  throat  violently,  in  vain  endeavors  to 
relieve  himself,  and  begs  and  prays  for  help.  The  respira- 
tion is  hard  and  rasping  in  character.  The  voice  is  usually 
husky,  but  it  may  be  clear  if  no  inflammation  is  present. 
More  difficulty  is  experienced  during  inspiration  than  with 


174  EMERGENCIES,  AND   IIOW  TO  TREAT  THEJI. 

expiration,  owing  to  the  fiict  that  the  pendulous  baga  of 
serum  at  the  edge  of  the  larynx  are  forced  down  by  the 
current  of  air,  and  almost  completely  close  up  the 
canal. 

The  expiratory  act  will  be  found  comparatively  free.  If 
laryngeal  inflammation  be  present,  both  inspiration  and 
expiration  will  be  difficult.  On  examination  of  the  throat 
the  epiglottis  may  be  seen  enlarged  and  prominent,  and, 
if  the  linger  be  carefully  inserted,  the  puffy,  o^dematous 
swelling  is  readily  felt.  If  the  symptoms  are  not  relieved, 
the  patient  soon  dies  asphyxiated.  The  duration  of  oedema 
glottidis  is  variable.  It  may  destroy  life  in  a  few  moments, 
or  it  may  last  for  hours  before  a  fatal  termination. 

Treatment. — There  is  no  time  for  vacillation  in  these 
cases.  Some  measure  for  relief  must  be  instituted  without 
delay.  Should  the  affection  be  complicated  with  laryngitis, 
and  the  dyspnoea  not  very  urgent,  a  brisk  cathartic  may  be 
given,  and  leeches  may  be  applied  to  the  top  of  the  sternum, 
and  at  the  sides  of  the  neck.  Leeches  should  never  be 
applied  directly  to  the  larynx  in  inflammation,  as  a  great 
deal  of  local  cedema  generally  follows  the  bite. 

In  the  majority  of  cases  this  kind  of  treatment  will  not 
avail  much;  operative  measures  have  to  be  resorted  to. 
Local  scarification,  as  employed  by  Dr.  Buck,  of  this  city,  is 
highly  recommended.  In  performing  this  operation,  a 
curved  bistoury,  covered  almost  to  the  point  with  adhesive 
plaster,  is  used.  The  forefinger  of  the  left  hand  is  passed 
do^vIl  to  the  back  of  the  tongue  until  the  swelling  is  reached. 
The  knife  is  then  introduced,  following  the  finger  as  a 
guide,  and  the  bags  of  serum  are  punctured.  Great  care 
must  be  taken  not  to  wound  any  part  but  the  cedematous 


CEDEMA  GLOTTIDIS.  175 

itrictin-e,  or  the  flowing  of  blood  into  tlie  larnyx  may  choke 
the  patient  before  the  oedema  is  removed. 

Scarification  is  sometimes  rendered  extremely  difficnlt, 
because  of  the  efforts  at  vomiting  induced  by  the  irritation 
of  the  finger  in  the  throat.  In  such  cases  perseverance 
ceases  to  be  a  virtue,  and  tracheotomy  or  laryngotomy  should 
at  once  be  performed  {see  pages  89,  90).  Either  of  these 
operations  may  be  performed  in  all  serious  cases. 


CHAPTER  XYI. 

CONVULSIONS. 

Infantile  Convulsions. — Convulsions  from  Uraemic  Poisoning,  Cerebral  Extrava- 
sation, Hysteria,  Alcohol,  Epilepsy,  Tetanus. 

Synonymes. — Eclampsia,  Fits,  Falling-Sickness,  Spasms. 

A  convulsion  is  an  involuntary  contraction  of  one  or 
more  muscles,  "with  or  without  loss  of  consciousness.  The 
sensorial  and  intellectual  faculties  are  seldom  affected  ex- 
cept in  general  convulsions.  The  muscular  contractions 
may  be  either  tonic  or  clonic.  In  the  former  the  spasm 
is  continuous,  in  the  latter  each  contraction  is  followed  by 
relaxation.  The  spasmodic  movements  succeed  each  other 
with  rapidity.  Tonic  contractions  appertain  especially  to 
tetanus.  The  clonic  variety  is  peculiar  to  epilepsy  and  all 
other  classes  of  convulsions. 

Convulsions  depend  either  on  an  irritation  transmitted 
from  the  periphery  to  the  nerve-centres,  or  on  an  abnormal 
irritability,  arising  directly  in  the  nerve-centres,  which  calls 
forth  excessive  and  irregular  action  in  the  motor  nerves. 

According  to  Longet,  sensations  coming  from  the  pe- 
riphery to  the  brain  are  converted  into  motor  impulses 
through  the  tuber  annulare. 

Irritation  of  this  ganglion,  whether  proceeding  from  ex- 
ternal sources  or  acting  through  the  blood,  will  excite  in-eg- 
ular  muscular  movements  throughout  the  body. 


CONVULSIONS.  177 

Convulsions  are  merely  symptomatic  phenomena,  repre- 
senting diverse  pathological  conditions  ;  the  significance  of 
a  convulsion,  therefore,  depends  upon  its  cause :  it  may  be 
the  premonition  of  death,  or  only  the  result  of  indigestion. 
Convulsions  may  occur  at  any  age,  but  they  are  most  fre- 
quent during  infancy. 

The  rapidly-developing  delicate  tissues  of  the  child  pos- 
sess a  susceptibility  which  intensifi.es  every  irritation,  and 
slight  causes  will  excite  irregular  action  and  disarrange  the 
nervous  system.  As  children  advance  in  years  this  sensi- 
bility decreases,  and  consequently  they  are  less  liable  to 
convulsive  attacks.  In  adult  life,  except  under  the  form  of 
epilepsy,  they  are  comparatively  rare. 

Infantile  convulsions  usually  occur  during  the  first  den- 
tition and  early  part  of  that  period.  The  first  few  months 
after  birth  give  the  greatest  percentage  of  cases.  Convul- 
sions in  utero  have  been  recorded  by  some  observers. 

Children  whose  parents  have  been  subject  to  eclamptic 
attacks  are  more  liable  than  others  to  the  afifection.  Causes 
insignificant  in  themselves  develop  this  hereditary  ten- 
dency. A  debilitated  state  of  the  system  is  a  predisposing 
cause.  Those  who  have  soft  skulls  from  rachitis  suffer  fre- 
quently from  convulsions.  As  exciting  causes  may  be  enu- 
merated :  indigestion,  worms  in  the  alimentary  canal,  teeth- 
ing, burns,  scalds,  eruptions,  foreign  bodies  penetrating  the 
integuments,  the  application  of  mustard-poultices,  and  blis- 
ters, fright,  affections  of  the  brain,  such  as  meningitis,  con- 
gestion, tumors  ;  exanthematous  disorders  ;  degenerations 
of  the  kidneys,  pneumonia,  bronchitis,  etc. 

The  attack  in  many  instances  can  be  traced  to  indiges- 
tion, solid  food  in  the  alimentary  canal,  unhealthy  milk,  and 
12 


178  EMERGENCIES,  AXD  HOW  TO  TREAT  THEII. 

aj-row-root,  or  other  articles  partially  cooked,  and  remaining 
unacted  upon  by  the  digestive  fluid.  An  irritation  is  coii- 
sequently  produced,  whicli  is  carried  by  the  sensory  nerves 
to  the  brain,  and  convulsions  follow.  Worms  in  the  ali- 
mentary canal  have  a  direct  irritating  action  upon  the  mu- 
cous membrane  of  the  intestines.  They  also  diminish  the 
digestive  functions,  and  lovrer  the  vitality  of  the  system ; 
hence  both  causes,  acting  together,  may  excite  the  abnormal 
muscular  movements. 

During  the  first  dentition,  convulsions  are  remarkably 
frequent.  In  fact,  the  great  majority  of  diseases  peculiar 
to  infancy  develop  during  the  evolution  of  the  teeth.  At 
this  time  the  swollen  and  tender  gums  give  rise  to  constant 
irritation.  The  child  becomes  fretful  and  feverish,  and  if 
there  happen  to  be  a  very  slight  predisposition  to  convulsive 
attacks  we  may  depend  upon  their  occurrence.  Convulsions 
proceeding  from  the  reflex  irritation  of  teething  are  said  to 
be  more  serious  than  other  varieties,  and  paralysis  is  not  an 
uncommon  sequence. 

Irritating  applications  to  the  integument,  in  the  form 
of  blisters  or  mustard-poultices,  are  attended  with  danger. 
Great  care  should  be  exercised  in  their  application.  A  blis- 
ter scarcely  two  inches  square  may  cause  alarming  attacks. 

Diseases  of  the  brain  in  children  are  usually  marked 
during  some  part  of  their  course  by  convulsions.  In  acute 
hydrocephalus  they  occur  in  the  later  stages  of  the  disease — ■ 
exceptionally  they  appear  in  the  first  stage. 

Many  of   the  narcotic    medicines    cause   convulsions. 
Poisoning  by   stramonium-seeds  is  not  uncommon.     The 
only  reliable  test  of  this  occurrence  is  the  presence  of  the 
-seeds  in  the  matter  vomited. 


CONVULSIONS.  179 

Convulsive  movements  may  affect  all  tlic  muscles  of  the 
body,  involuntary  as  well  as  voluntary,  or  be  limited  to  a 
single  muscle,  or  to  one  set  of  muscles ;  one  side  of  the  body 
may  alone  be  convulsed,  or  alternate  convulsions  of  each 
side,  or  of  different  limbs,  may  take  place. 

In  the  affection  known  as  inward  convulsions  the  dia- 
phragm, the  muscles  of  the  abdomen  and  thorax,  and  oc- 
casionally the  muscles  of  the  larynx,  are  involved. 

The  symptoms  of  eclampsia  can  conveniently  be  divided 
into  premonitory  and  immediate.  The  premonitory  signs, 
however,  are  not  always  present. 

Tor  a  variable  length  of  time  preceding  the  fit,  the  child 
may  be  feverish  and  restless.  The  sleep  is  disturbed,  and 
muscular  twitchings  are  observed.  If  teething,  tlie  child 
moans,  moves  its  head  about,  and  the  jaws  are  worked  from 
side  to  side.  If  undigested  food  or  worms  are  present,  there 
will  be  a  tympanitic  abdomen,  and  eructations  of  gas  from 
the  intestinal  canal.  In  brain-affections,  the  abdomen  is 
flattened ;  there  may  be  vomiting,  projectile  in  character, 
and  without  nausea.  There  is  pain  in  the  head,  and,  when 
carried  rapidly  from  one  place  to  another,  the  child  screams 
violently. 

The  convulsive  movements  commence  suddenly.  The 
child  cries  sharply,  and  falls.  The  muscles  for  a  moment 
become  rigid.  The  corners  of  the  mouth  are  drawn  down, 
the  eyes  are  either  fixed  or  oscillating,  generally  the  former. 
There  may  be  either  convergent  or  divergent  strabismus. 
Respiration  ceases.  The  child's  face,  which  was  at  first 
pale,  becomes  livid,  the  veins  of  the  face  and  neck  are 
turgid  and  filled  with  blood,  and  a  gurgling  noise  is  heard 
in  the  throat.     The  rigid  condition  of  the  muscles,  or  tonic 


[80      EMERGENCIES,  AND  HOW  TO  TREAT  THEil. 

coiitractious,  continue  but  a  few  seconds,  and  they  are  suc- 
ceeded by  alternate  contractions  and  relaxations,  or  clonic 
spasms.  The  limbs  are  moved  violently  about,  rapidly 
extended  and  flexed.  These  clonic  movements  cease,  and 
the  patient  sinks  into  a  deep  sleep  or  a  semi-comatose  con- 
dition. 

The  convulsivo  movements  in  children  usually  continue 
longer  than  in  adults.  The  whole  paroxysm  lasts  from 
half  a  minute  to  two  minutes,  or  even  longer.  The  fits 
may  succeed  each  other  with  such  frequency  as  to  seem 
continuous,  but  this  is  rare.  The  immediate  effects  pro- 
duced by  the  muscular  contractions  are  worthy  of  notice. 
They  may  be  witnessed  in  all  kinds  of  convulsions.  The 
abdominal  muscles,  by  pressure  on  the  intestines  and  blad- 
der, may  expel  the  faeces  and  urine.  It  is  not  unusual  for  a 
fit  to  terminate  in  this  manner.  The  spasm  of  the  respira- 
tory muscles,  including  those  which  govern  the  glottis,  pre- 
vents ingress  and  egress  of  air,  and  a  partial  asphyxia  is  the 
consequence.  The  pressure  of  the  muscles  at  the  base  of 
the  neck,  and  the  non-expansion  of  the  chest,  by  j^reventing 
the  venous  blood  from  leaving  the  head,  cause  congestion 
of  the  brain.  The  muscles  which  act  upon  the  tongue  pro- 
trude it  from  the  mouth.  "When  this  occurs  during  the 
spasmodic  action  of  the  muscles  of  mastication,  the  tongue 
is  caught  between  the  teeth  and  severely  lacerated.  Spasm 
of  the  vessels  of  the  pia  mater  is  said  to  produce  insensi- 
bility. 

All  the  symptoms  described  are  common  to  true  epi- 
lepsy, and  it  is  impossible  to  distinguish  them  during  the 
fit.  In  infantile  convulsions  the  period  of  spasmodic  action 
is  continued  over  a  greater  length  of  time  than  in  true  epi- 


CONVULSIONS.  181 

lepsy.  The  history  of  the  case  will  be  of  asaistance  in  de- 
termining its  true  nature.  For  instance,  in  epilepsy,  wo 
would  probably  learn  that  the  patient  had  had  fits  before, 
coming  at  comparatively  long  intervals,  and  without  appar- 
ent cause.  In  the  other  case  there  would  be  evidences  of 
worms  in  the  alimentary  canal,  of  indigestion,  or  some  of 
the  other  special  causes  previously  enumerated.  Again,  the 
occurrence  of  attacks  rapidly  following  each  other  would 
be  rather  strong  evidence  that  they  were  not  epileptic. 

A  rigid  condition  of  one  or  more  muscles,  after  conscious- 
ness is  restored,  is  an  unfavorable  sign,  often  indicating 
injury  to  some  part  of  the  brain  or  spinal  cord.  These  con- 
vulsions usually  cease  when  the  exciting  cause  is  removed, 
but  the  possibility  of  a  fatal  termination  must  not  be  over- 
looked. 

Convulsive  attacks  may  occasion  death — 1.  By  asphyxia; 
2.  Congestion  of  the  cerebrum,  or  other  injury  to  the  nerve- 
centres  ;  3.  Syncope ;  4.  Gradual  exhaustion  from  successive 
or  protracted  convulsions. 

Post-mortem  appearances  are  of  little  value  in  deter- 
mining the  causes  of  the  affection.  The  congestion  of  the 
brain  and  spinal  cord,  which  we  find,  is  probably  the  result 
of  the  convulsion,  and  not  its  cause. 

Among  the  varied  sequels  of  infantile  convulsions  we 
find  paralysis  of  different  parts.  It  may  appear  in  one 
limb,  or  in  one  set  of  muscles,  or  may  involve  the  lower 
half  or  lateral  half  of  the  body.  Recovery  from  it  is  rare. 
Convergent  and  divergent  strabismus  likewise  occur,  the 
latter  most  frequently.  Idiocy  may  result  from  continu- 
ous convulsions. 

A  loss  of  coordinating  power  in  the  muscles  which 


[S2  EMERGENCIES,  AND  HOW  TO  TREAT   THEM. 

produce  .  articulate  sounds   sometimes   occasions  stammer- 
ing. 

Amaurosis  and  deafness  also  occur.  Yerj  little  can  be 
done  to  relieve  them. 

Treatment. — The  preventive  treatment  consists  in  at- 
tending to  the  general  health  of  the  child,  and  placing  it 
under  proper  hygienic  influences.  Its  food  should  be  of 
good  quality,  its  nurse  healthy,  the  sleeping-apartment  well 
A'entilated,  the  clothing  loose  and  not  heavy.  If  worms  are 
present,  they  must  be  removed  by  anthelmintics.  Indiges 
tion  should  be  relieved  immediately  by  the  ordinary  means. 
Sores  or  ulcers  of  the  integument  are  treated  with  emollient 
applications,  and  with  sedatives  internally. 

During  the  paroxysm,  efforts  are  made  to  relieve  the 
severity,  and  as  far  as  possible  prevent  a  recurrence  of  the 
attack. 

The  child  should  at  once  be  stripped  and  immersed  in  a 
hot  bath.  A  tablespoonful  of  mustard  added  to  the  water 
will  increase  its  efficacy.  The  child  may  remain  in  the 
bath  from  two  to  four  minutes  at  a  time.  Some  recommend 
firm  pressure  around  one  arm  and  leg  on  opposite  sides  of 
the  body.  This  procedure  is  of  benefit  in  that  variety  of 
spasm  called  by  Trousseau  ^(?to?22//  but  in  this  affection  it 
would  be  of  little  service.  As  soon  as  the  paroxysm  has 
ceased  the  bowels  should  be  emptied  with  castor-oil,  or  by 
injections  of  warm  water.  After  the  evacuation  the  follow- 
ing may  be  administered,  by  enema — 

^..  Misturso  assafcetidsD fl.  3S3. 

AqusB fl.  §  j.    M. 

and  repeated  when  necessary.    Bromide  of  potassium,  in  one 


CONVULSIONS,  183 

or  two  grain  doses,  is  also  a  valuable  remedy.  The  dose  of 
this  may  be  increased  if  desired.  Should  the  convulsions 
be  violent,  protracted  inhalations  of  chloroform  may  be  em- 
ployed, and  repeated  with  benefit. 

Convulsions  arising  from  cerebral  lesions,  such  as  inflam- 
mation, etc.,  wall  not  give  way  to  the  treatment  recom- 
mended. This  variety  might  as  well  be  let  alone,  as  it 
usually  terminates  fatally. 

In  all  convulsive  attacks  a  rigid  investigation  into  the 
cause  of  the  convulsion  should  be  instituted,  and  treatment 
directed  to  its  removal  should  be  commenced  without 
delay. 

CONVULSIONS   IN   THE   ADULT. 

Convulsions  in  the  adult  acquire  an  importance  w^hich 
they  do  not  possess  during  infantile  life.  In  many  cases 
they  indicate  the  presence  of  constitutional  lesions,  which 
may  bring  about  a  fatal  termination  in  a  short  period.  An 
extended  description  of  the  diseases  which  give  rise  to  these 
convulsions  is,  with  the  limited  space  at  command,  inad- 
missible. All  the  prominent  features  of  each  condition,  and 
especially  the  different  signs  which  lead  to  a  correct  diag- 
nosis, will,  however,  be  fully  considered.  These  points  of 
difference  cannot  be  too  closely  observed,  and  they  should 
be  studied  more  carefully  than  the  points  of  resemblance. 

These  convulsions  may  be  classed  under  five  separate 
heads  :  1.  Those  which  arise  from  the  retention  of  urea  in 
the  blood  in  disease  of  the  kidneys,  viz.,  ursemic  convulsions  ; 
2.  Convulsions  which  characterize  epilepsy  ;  3.  Those 
arising  from  affections  of  the  brain,  such  as  extravasations 
of  blood  in  its  substance,  or  upon  its  surface ;   4.  Hysterical 


184     EMERGENCIES,  A^'D  HOW  TO  TREAT  THEM. 

convulsions,  and  5.  Convulsions  due  to  the  excessive  use  of 
alcohol. 

1.  UKJEiiic  Convulsions. — In  the  chapter  on  uroemic 
coma,  the  source  and  character  of  the  poison  {urea)  which 
accumulates  in  the  blood  in  Bright's  disease  of  the  kidneys 
were  fully  considered.  It  is  said  to  act  on  the  base  of  the 
brain  and  medulla  like  any  other  irritant,  calling  forth 
irregular  and  violent  muscular  movements. 

These  convulsions  may  also  be  due  to  oedema  of  the 
brain-substance,  which  exists  in  common  with  oedema  of 
other  parts  in  Bright's  disease  {Boberts).  The  pressure  of 
the  effused  serum  empties  the  arteries,  and  diminishes  the 
amount  of  blood  in  the  organ. 

Preceding  the  commencement  of  the  convulsion,  the 
patient  complains  of  headache,  dimness  of  vision,  dizziness 
and  other  symptoms  referable  to  the  nervous  system.  The 
stomach  is  irritable,  and  the  bowels  are  usually  relaxed. 
The  countenance  has  a  pale,  waxy  appearance.  There  is 
oedema  under  the  eyes.  Pressure  on  the  lower  limbs  may 
leave  a  pit  or  indentation  under  tlie  finger,  showing  the 
presence  of  oedema.  Coma  may  or  may  not  occur  before 
the  paroxysm.  The  urine  may  be  scanty,  and  of  a  high 
color. 

It  must  not,  however,  be  forgotten  that  uraemic  convul- 
sions, occurring  with  the  small  contracted  kidney,  may  have 
none  of  these  characteristic  symptoms  of  diseased  kidney 
preceding  them. 

The  paroxysm  appears  suddenly.  The  body  and  extremi- 
ties become  violently  convulsed.  Spasmodic  contractions 
of  the  clonic  variety  succeed  each  other  rapidly.  The  face 
becomes  livid,  the  eyes  are  glassy  and  fixed,  or  may  oscillate 


CONVULSIONS.  185 

from  Bide  to  side  (m/stagmus).  The  pupils  are  contracted 
or  dilated,  usually  the  latter.  Froth,  mixed  sometimes  with 
blood,  collects  around  the  mouth,  and  in  exceptional  cases 
the  tongue  may  be  bitten.  There  is  a  strong  urinous  odor 
emanating  from  the  perspiration.  When  the  convulsions 
cease,  the  patient  sinks  into  a  deep  coma,  which  usually 
ends  in  death.  Tliere  may  be  only  one  convulsion,  or  the 
convulsions  may  succeed  eacli  other  at  short  intervals  for 
several  hours.  The  points  of  difference  which  distinguish  a 
ursemic  convulsion  from  epilepsy,  or  from  apoplectic  convul- 
sions, require  careful  investigation. 

In  ursemic  convulsions  both  sides  of  the  body  are  equally 
affected  by  the  spasmodic  movements.  In  epilepsy  one  side 
is  convulsed  more  violently  than  the  other.  There  are  few 
exceptions  to  this  rule.  In  ursemia  we  find  oedema  of  the 
face  and  extremities,  and  urinous  odor  to  the  perspiration, 
which  are  generally  absent  in  cerebral  extravasation  and  in 
epilepsy.  A  chemical  and  microscopical  examination  of  the 
urine  will  probably  show,  in  uraemia,  albumen,  and  fatty, 
granular,  or  hyaline  casts,  while  in  epilepsy  and  cerebral 
extravasation  they  are  usually  absent.  In  one  case  we  have 
an  antecedent  history  of  Bright's  disease  of  the  kidneys ; 
in  epilepsy  a  history  of  previous  convulsions,  with  perfect 
health  during  the  intervals.  The  tongue  is  generally  bitten 
in  true  epilepsy,  rarely  in  a  uraemic  convulsion.  Following 
the  latter,  there  is  deep  coma ;  in  the  former  merely  a  deep 
sleep,  from  which  the  patient  may  be  aroused.  In  cerebral 
extravasation  there  is  paralysis  with  irregularity  of  the 
pupils,  which  is  not  present  in  uraemia.  In  the  former  also 
there  is  sometimes  rigidity  of  the  muscles  following  the 
attack ;  in  the  latter,  this  is  rarely  manifested.     The  treat- 


£86  EMERGENCIES,  AND  HOW   TO  TREAT  THEM. 

ment  of  un-eraic  convulsions  is  similar  to  that  pursued  in 
ura^mic  coma  [see  Coma). 

PuERPEKAL  Convulsions. — Convulsive  attacks  are  not 
unusual  during  the  period  of  ntero-gestation,  particularly 
toward  its  termination.  They  may  arise  from  hysteria, 
epilepsy,  etc.,  but  the  vast  majority  are  due  to  uraemic 
poisoning.  The  enlarged  uterus  presses  upon  the  blood- 
vessels of  the  kidney,  causing  congestion  of  that  organ,  and 
subsequent  retention  of  urea  in  the  blood.  For  a  vari- 
able period  previous  to  the  convulsive  seizure,  the  woman 
may  present  all  the  ordinary  signs  of  Bright's  disease  {see 
IJrsemic  Coma).  The  convulsion  is  similar  in  all  its  features 
to  that  previously  described. 

The  seizure  may  cause  the  death  of  the  child  in  utero. 
The  placenta  may  be  compressed,  so  as  to  prevent  the  foetal 
blood  from  being  aerated,  or  the  child  may  be  poisoned  by 
the  urea,  and  die  in  a  convulsion. 

Treatment. — Inhalations  of  chloroform  are  employed  to 
stop  the  convulsion.  Should  the  attacks  continue,  prema- 
ture labor  must  be  induced,  and  the  uterus  emptied  of  its 
contents.  If  the  cervix  is  undilated,  sponge -tents  may  be 
inserted.  AVhen  these  have  enlarged  the  canal  somewhat, 
Barnes's  dilators  are  passed  up,  and  distended  with  water 
to  such  an  extent  as  to  thoroughly  dilate  the  cervix.  A 
catheter  introduced  between  the  membranes  and  walls 
of  the  uterus  is  sometimes  employed  to  hasten  delivery. 
When  the  cervix  has  been  suflSciently  dilated,  the  child  is 
delivered  by  version,  or  with  forceps. 

The  subsequent  treatment  consists  in  eliminating  the 
poison  from  the  blood  of  the  patient,  and  building  up  the 
liealth  by  tonics  and  good  diet. 


CONVULSIONS.  187 

Epileptic  Convulsions  are  more  common  than  any  other 
variety.  They  may  arise  at  any  period  of  life.  The  largest 
proportion  of  cases,  however,  occur  between  the  ages  of 
ten  and  twenty  {Reynolds).  But  little  is  known  as  to  the 
pathology  of  the  disease.  Among  the  numerous  causes 
given  are :  1.  Cerebral  anaemia  arising  from  spasmodic  con- 
traction of  the  vessels  which  supply  the  brain,  diminishing 
the  quantity  of  blood  going  to  that  organ.  2.  Irregular 
distribution  of  blood  to  the  brain,  giving  an  over-supply  to 
one  part  of  the  organ,  and  too  little  to  another,  exalting  the 
excitability  in  one  portion,  and  diminisliing  it  in  the  other. 

3.  Excessive  sensibility  and  excitability  of  the  medulla  ob- 
longata, with  or  without  spasm  of  its  vessels  {Hammond). 

4.  Softening  of  the  pituitary  body.  5.  Induration  of  brain- 
substance  ;  and,  6.  Thinning  and  dilatation  of  the  cerebral 
blood-vessels,  with  resulting  anaemia,  and  exalted  excitability 
of  the  medulla. 

Epilepsy  is  often  connected  with  masturbation,  venereal 
excesses,  syphilis,  cerebral  tumors,  fright,  etc.,  etc. 

How  far  venereal  excesses  and  syphilis  tend  to  develop 
the  disease  is  uncertain,  unless  by  increasing  the  general 
excitability  of  the  nervous  system,  and  by  lowering  the 
general  health. 

Cerebral  tumors  excite  convulsions  by  direct  imtation, 
but  we  cannot  place  them  under  the  head  of  true  epilepsy 
any  more  than  those  arising  from  cerebral  extravasation,  or 
uraemia. 

Many  authorities  give  two  varieties  of  true  epilepsy :  a 
mild  form  i^e  jpetit  maV),  where  there  is  sudden  unconscious- 
ness, and  little  or  no  spasm ;  and  le  Tiwut  Tnal,  where  the 
loss  of  consciousness  is  complete,  and  the  convulsive  move-. 


188  EMERGENCIES,  AND   HOW  TO   TREAT   THEM. 

ments  general.  It  is  very  evident  that  there  are  two  forms 
of  epilepsy,  differing  in  severity,  but  "sve  can  hardly  apply 
the  term  epilepsy  to  every  slight  loss  of  consciousness,  or 
"  absence,"  ■without  convulsive  movement.  Many  persons 
have  moments  of  partial  unconsciousness,  who  have  never 
had  muscular  twitchings  of  any  sort,  and  who  are  free  from 
hereditary  taint.  These  persons  are  anaemic,  dyspeptic,  or 
both,  and  the  attacks  partake  more  of  the  nature  of  syncope 
than  any  thing  else.  I  am  acquainted  with  a  gentleman 
who  is  affected  suddenly  once  or  twice  in  the  month  "with 
partial  or  complete  unconsciousness.  It  always  takes  place 
immediately  after  a  hearty  dinner,  and  is  without  spasm  of 
any  kind.  Occasionally  it  is  connected  with  a  little  ver- 
tigo. Such  cases  should  not  be  classed  under  the  head  of 
epilepsy. 

A  true  epileptic  attack  is  commonly  preceded  by  a  warn- 
ing called  the  epileptic  aura.  Strictly  speaking,  this  term 
does  not  apply  to  all  varieties  of  altered  sensation  which 
give  notice  of  the  coming  fit,  but  only  to  those  which  give 
the  feeling  of  a  wind  or  breeze  blowing  on  the  person. 
However,  as  it  is  in  common  use,  it  will  be  retained  in  this 
connection.  This  premonitory  symptom  assumes  different 
forms.  Sometimes  it  consists  in  a  general  feeling  of  weak- 
ness, or  of  unpleasant  sensations  in  the  ei)igastrium  or 
head.  It  may  be  a  sharp  pain  in  one  extremity  or  the 
other,  which  seems  to  extend  upward  until  it  reaches  the 
head,  when  the  paroxysm  appears.  These  warnings  are  not 
}')resent  in  all  cases.  At  the  commencement  of  the  attack 
the  patient  usually  utters  a  loud  cry,  and  falls  suddenly  to 
the  ground,  completely  unconscious.  The  countenance  is 
^pallid.     All  the  muscles  are  fixed  in  a  tonic  spasm.     The 


CONVULSIONS.  189 

pulse  sometimes  cannot  be  distinguished  at  the  wrist,  owing 
to  the  contraction  of  the  muscles.  Respiratory  movements 
have  ceased.  The  eyes  are  fixed,  the  pupils  dilated.  Some 
say  that  the  pupils  are  contracted  in  tlie  early  part  of  the 
stage,  but  this  is  doubtful.  This  condition  of  tonic  spasm 
lasts  from  ten  seconds  to  half  a  minute,  when  the  clonic 
spasms  commence.  The  countenance  is  now  engorged  with 
blood  and  livid.  The  blood-vessels  of  the  face  and  neck 
are  distended  enormously.  Bloody  foam  collects  around  the 
mouth.  The  eyes  roll  from  side  to  side.  The  pulse  is  full 
and  labored.  The  clonic  stage  continues  from  thirty  sec- 
onds to  one  minute.  All  the  muscles  then  relax  and  the 
patient  sinks  into  a  deep  sleep,  which  may  last  several 
hours.  In  these  typical  cases  of  epilepsy  the  patient  is 
entirely  without  knowledge  of  the  fit  when  consciousness  is 
restored.  Sometimes  epileptic  fits  take  place  during  the 
night  and  continue  for  some  time,  the  person  being  utterly 
ignorant  of  them.  He  only  knows  that  he  wakens  in  the 
morning  with  sore  limbs  and  wounded  tongue.  These 
night-fits  are  apt  to  be  milder  in  form  than  those  occurring 
during  the  waking  hours. 

The  sequelae  of  epilepsy  are  idiocy  and  insanity.  Long- 
continued  attacks  are  often  followed  by  either  one  or  the 
other  of  these  afiections.  When  they  reach  this  point,  very 
little  can  be  done  to  remove  the  disease.  A  fatal  termina- 
tion is  so  extremely  rare  in  epilepsy  that  we  are  not  in  pos- 
session of  any  peculiar  or  charsLctevistiG  post-mortem  changes. 
The  points  of  difference  between  an  epileptic  convulsion 
and  one  arising  from  urasmic  poisoning  have  already  been 
given.  Epilepsy  is  easily  diagnosed  from  hysteria.  In  epi- 
lepsy there  is  complete  unconsciousness,  and  the  patient 


[90  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

falls,  ^vllel•ever  she  may  be,  sometimes  into  the  fire  or  down 
the  stairs.  In  hysteria  the  patient  knows  every  thing  that  is 
going  on,  as  can  he  ascertained  by  watching  the  eyes;  and 
she  will  fall  in  a  soft,  comfortable  place,  where  there  is  little 
danger  of  receiving  injury.  Hysterical  spasms  are  not  so 
violent,  nor  is  the  tongue  bitten,  as  in  epilepsy.  The  face 
is  not  livid,  and  usually  there  is  a  choking  sensation  as  if 
a  ball  were  rising  in  the  throat. 

These  convulsions  arc  sometimes  feigned  by  a  class  of 
persons  called  malingerers.  Such  cases  are  recognized  by 
the  fact  that  respiration  does  not  cease,  nor  is  the  tongue 
bitten.  The  malingerer  never  falls  where  he  is  likely  to 
hurt  himself,  and  threats  to  use  hot  irons  or  hoc  water  will 
bring  about  a  speedy  recovery. 

From  apoplexy  it  is  distinguished  by  the  absence  of  ir- 
regularity of  the  pupil,  of  paralysis,  and  also  by  the  fact 
that  the  subsequent  coma  is  complete. 

Cekebeal  Extravasation. — Convulsions  from  this  cause 
are  extremely  rare. 

The  patient  previous  to  the  convulsion  may  be  affected 
with  muscular  twitchings  about  the  face  or  slight  numbness 
in  one  of  the  extremities.  He  may  complain  of  a  "  fulness  " 
about  the  head,  and  severe  pain.  The  fit  comes  on  sud- 
denly, at  the  time  of  the  extravasation.  Convulsions  from 
cerebral  extravasation  resemble  the  convulsions  already  de- 
scribed, in  all  the  main  features  and  symptoms. 

The  pupils  are  usually  irregular,  one  contracted  and  the 
other  dilated,  or  they  may  be  both  dilated.*  There  is 
always  paralysis,  generally  of  one  lateral  half  of  the  body  ; 

*  There  is  an  exception  to  ttiis  in  extravasation  of  blood  into  the  pons 
Varolii-     In  that  case,  the  pupils  are  markedly  contracted. 


CONVULSIONS.  191 

but  this  Ib  not  clearly  manifested  until  the  subsidence  of  tlie 
convulsion.  When  the  spasms  have  ceased,  tlie  patient 
exhibits  all  the  signs  of  compression  of  the  brain — such  as 
deep  coma,  slow,  full  pulse,  dilated  pupils — and  lie  cannot 
usually  be  roused  from  his  stupor.  In  epilepsy  the  patient 
is  easily  aroused. 

The  absence  of  albumen  and  casts  in  the  urine,  and  of 
cedema  of  the  extremities,  will  be  sufficient  in  most  cases  to 
exclude  ursemic  poisoning.  The  fact,  however,  of  the 
occurrence  of  Bright's  disease  in  connection  with  apoplectic 
extravasation  must  not  be  overlooked.  Such  cases  are  not 
unfrequent.  The  presence  of  paralysis  will  under  such  cir- 
cumstances lead  the  practitioner  to  the  real  seat  of  the 
lesion. 

Treatment. — If  the  patient  is  full-blooded  and  plethoric, 
and  the  pulse  full  and  hard,  the  abstraction  of  nine  or  ten 
ounces  of  blood  from  the  arm  will  be  decidedly  beneficial. 
Even  if  it  does  not  relieve  in  a  marked  degree  the  severity 
of  the  convulsive  attacks,  it  will  lessen  the  intra-cranial  con- 
gestion, and  thereby  the  danger  of  further  extravasation. 

When  the  patient  is  not  plethoric,  and  when  other  dis- 
eased conditions  tend  to  decrease  the  vital  force,  blood- 
letting should  be  avoided.  The  treatment  in  such  cases  is 
limited  to  the  prevention  of  inflammation,  absorption  of  the 
clot,  and  restoration  of  power  to  the  paralyzed  parts  {see 
article  on  Coma). 

KUM  CONVULSIONS. EUM   EPILEPSY. 

Persons  who  indulge  freely  in  alcoholic  stimulants  not 
unfrequently  suffer  from  spasmodic  attacks  resembling 
those  of  true  epilepsy.     The  affection  arises  probably  from 


192      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

irritation  produced  in  the  nerve-centres  by  the  alcohol,  and 
also  from  congestion  of  the  same  parts.  Much  difficulty  is 
encountered  during  the  attack  in  distinguishing  its  true 
character.  It  Avill  be  found,  however,  that  the  tongue  is 
not  bitten,  nor  is  one  side  of  the  body  more  convulsed  than 
the  other,  as  in  true  epilepsy.  The  history  of  a  long-con- 
tinued "  spree,"  and  the  odor  of  alcohol,  will  also  serve  to 
distinguish  them. 

It  is  also  necessary  to  decide  between  these  convulsions 
and  those  due  to  cerebral  extravasation.  Here,  again,  the 
presence  of  paralysis  is  an  important  feature.  It  is  never 
found  in  simple  rum  convulsions.  Following  the  latter 
there  is  also  a  stupor  from  which  the  patient  is  readily 
aroused,  while  in  apoplexy  the  coma  is  persistent.  Here 
the  history  of  the  case  is  likewise  of  advantage. 

Treatinent. — Daring  the  attack  little  is  to  be  accom- 
plished by  treatment.  Subsequently  cold  water  may  be 
poured  on  the  face,  and  opium  or  bromide  of  potassium 
may  be  given  to  moderate  the  nervous  irritability,  and  pro- 
mote sleep. 

Hysterical  Convulsions  are  peculiar  lo  young  unmar- 
ried females  ;  but  they  may  occur  in  the  married  state  or  in 
advanced  life.  Delicate  women  of  nervous  temperaments 
and  excitable  dispositions  are  generally  the  subjects.  The 
disease  is  often  connected  with  functional  or  organic  disease 
of  the  generative  organs ;  unsatisfied  and  uncontrollable 
passions,  masturbation,  etc.,  are  not  unfrequent  causes. 

The  patient  for  some  time  previous  to  the  attack  may 
complain  of  a  sensation  in  the  throat,  as  if  a  ball  were 
rising  up  and  choking  her  {globus  hystericus),  or  she  may  be 
affected  with  violent  fits  of  laughter  and  crying,  or  with 


CONVULSIONS.  193 

Bome  of  the  other  varied  forms  of  hysterical  manifestations. 
As  the  attack  appears  the  patient  sinks  down  in  a  comfort- 
able spot  where  there  is  no  danger  of  injury.  The  limbs 
are  jerked  about  irregularly,  and  with  less  force  than  in  an 
epileptic  convulsion.  The  breathing  is  jerking  and  spas- 
modic ;  sometimes  she  appears  as  if  choking.  She  shrieks 
loudly  at  one  moment,  and  at  another  mutters  incoherently ; 
close  inspection  will  show  that  the  patient  is  not  uncon- 
scious, and  that  the  pupils  are  in  a  normal  condition.  There 
is  none  of  that  lividity  of  the  face  or  distention  of  the  blood- 
vessels which  is  characteristic  of  epilepsy.  The  paroxysm 
may  terminate  in  another  fit  of  crying  or  laughing,  or  it 
may  be  followed  by  sleep.  Often  its  close  is  accompanied 
by  the  discharge  of  a  large  quantity  of  pale  urine. 

Treatment. — A  pitcher  of  cold  water  should  be  poured 
slowly  on  the  face  and  head.  This  procedure  may  be 
repeated  until  the  convulsion  ceases.  Should  the  attack  be 
repeated,  a  shower-bath  will  be  found  an  excellent  remedy. 
In  very  delicate  females,  however,  this  would  not  answer, 
but  the  cold  douche  to  the  head  can  be  employed  without 
injury. 

The  subsequent  treatment  has  reference  to  the  general 
weakened  nervous  system  of  the  patient.  Cold  bathing, 
tonics,  antispasmodics,  good  diet,  and  the  practice  of  self- 
control,  should  be  recommended. 

Tetanic  Convulsions  occur  in  tetanus.  The  disease 
arises  generally  from  traumatic  causes,  such,  as  wounds 
from  rusty  nails,  etc.,  involving  branches  of  nerves.  Some 
cases  arise  from  cold.  The  convulsions  are  caused  by  ir- 
ritation of  the  spinal  cord,  which,  has  been  excited  by  in- 
jury of  the  peripheral  nerve.  They  are  tonic  in  eharacter, 
13 


19i      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

and  extremely  violent.  When  the  muscles  ot  mastication 
are  aflfectedj  the  jaw  is  tightly  closed,  giving  rise  to  trismus 
or  locl'jaw.  "When  the  muscles  of  tlie  back  are  involved, 
the  body  is  arched  and  rests  on  the  head  and  heels  {oj)is- 
thotonos).  Contractions  of  the  muscles  on  the  anterior  sur- 
face bend  the  body  forvrard  {emj>rosthotonos)^  contractions 
of  one  side  give  a  lateral  inclination,  c?i\\ei\  jpleurosthotonos. 
When  tetanus  is  once  fully  established,  a  breeze,  the  creak- 
ing of  a  door,  and  other  slight  causes,  suffice  to  excite  a  con- 
vulsion. Tonic  spasm  of  the  respiratory  muscles  generally 
kills,  the  patient  dying  from  asphyxia. 

Treatment. — Anaesthetics,  opiates,  chloral,  or  assafoetida, 
can  be  administered  in  large  quantities. 


CHAPTEK  XVII. 

8USPEndi:d  fcetal   animation. 

Pressure  on  Umbilical  Cord. — Injury  to  Brain. — Eupture  of  Umbilical  Cord.— 
Asphyxia. — Syncope. — Congestion  of  Brain. 

DunmG  the  progress  of  labor  the  child  is  subject  to 
many  accidents  which  may  supend  for  a  time  the  functions 
of  life  or  completely  destroy  it.  Thus,  the  umbilical  cord 
may  be  pressed  upon  by  the  head  in  its  passage  through  the 
straits  of  the  pelvis ;  the  cord  may  be  wound  around  the 
neck ;  the  air-passages  filled  with  mucus  so  that  the  child's 
blood  remains  unaerated,  and  a  condition  of  asphyxia  in- 
duced. 

Profuse  haemorrhage,  due  to  rupture  of  the  cord  or  to 
separation  of  the  placenta,  occasions  another  variety  of  sus- 
pended fcetal  animation  known  as  syncope.  The  head  may 
be  compressed  in  the  maternal  passages,  or  by  instruments, 
with  such  severity  as  to  cause  congestion  of  the  brain. 

Of  these  three  conditions  asphyxia  is  most  commonly 
met  with.  The  child  in  this,  as  in  the  former  cases,  is  born 
apparently  lifeless.  The  face  is  swollen  and  of  a  dark-blue 
color,  and  the  lips  are  livid  and  everted.  The  extremities 
and  general  surface  may  present  a  similar  appearance. 

Pespiratory  movements  are  absent,  or  there  may  be  a 
slight  gasp,  repeated  at  long  intervals.     The  pulsations  of 


196      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

tlie  heart  are  extremelv  feeble ;  as  long  as  any  movement 
can  be  distinguisbed,  there  is  hope  of  resuscitation.  A 
favorable  result  is  scarcely  ever  obtained  vrhen  the  heart 
has  entirely  ceased  its  action.  In  cases  where  the  asphyxia 
is  produced  suddenly,  lividity  may  to  a  certain  extent  be 
absent,  but  this  is  rare. 

In  the  second  variety,  or  the  state  of  syncope,  the  child 
is  pale  and  cold.  The  lips  are  colorless.  Respiratory  move- 
ments are  sighing  in  character  or  absent.  The  extremities 
are  limber  and  flaccid.  The  pulse  cannot  be  detected  at 
the  wrist,  but  weak  pulsatory  movements  of  the  heart  may 
be  heard  with  a  stethoscope. 

"When  congestion  of  the  brain  exists  there  is  some  li- 
vidity about  the  head  and  face,  but  the  color  is  not  so  dark 
as  in  asphyxia,  and  the  capillaries  of  the  extremities  do  not 
present  the  same  blueness. 

Treatment. — In  all  cases  exertions  to  restore  life  should 
be  made  so  long  as  the  faintest  movement  of  the  heart  can 
be  detected.  Life  has  been  restored  after  an  hour's  labor, 
and  it  is  not  uncommon  for  a  child  to  remain  for  half  an 
hour  without  breathing,  and  yet  be  finally  restored.  Even 
when  respiration  has  been  established  tlie  treatment  should 
be  continued  until  the  cliild  cries  vigorously. 

In  the  first  variety,  where  asphyxia  exists,  the  child  may 
be  plunged  alternately  into  warm  and  cold  water  to  excite 
respiration  through  the  sensory  nerves  of  the  cutaneous 
surface.  Slapping  the  body  at  the  same  time  with  tlie  flat 
of  the  liand  is  also  beneficial.  In  mild  cases  this  method 
alone  will  answer.  Should  they  fail,  artificial  respiration 
by  Sylvester's  method  (see  chapter  on  Asphyxia),  or  inflating 
the  lungs  by  insufllation,  must  be  tried.     In  doing  this  the 


SUSPENDED  FCETAL  ANIMATIOX.  Ifj-^ 

mouth  and  throat  of  the  patient  must  he  cleared  of  mu- 
cus, the  larynx  j^ressed  against  the  spinal  column  to  pre- 
vent air  from  entering  the  oesophagus,  while  the  physician, 
with  his  lips  applied  to  those  of  the  child,  blows  steadily 
into  the  lungs  until  they  are  expanded  ;  when  this  is  done 
pressure  is  made  on  the  lateral  walls  of  the  thorax  to  force 
the  air  out.  Again  they  are  inflated  and  again  compressed 
until  the  respiratory  movements  are  naturally  performed. 
Sylvester's  method  is  preferred  above  all  others. 

The  chief  requirement  in  the  condition  of  syncope  is  to 
furnish  more  blood  to  the  child.  This  is  accomplished  by 
"stripping"  the  cord  from  the  placenta  toward  the  child's 
abdomen,  i.  e.,  pressing  the  blood  along  the  vessels  to  the 
child.  Friction  and  warmth  to  the  surface  are  also  neces- 
sary. 

In  the  congestive  variety  the  umbilical  cord  is  cut  at 
once  and  allowed  to  bleed  freely  for  a  few  minutes,  while 
the  surface  is  rubbed  and  respiratory  movements  assisted  by 
alternate  pressure  and  relaxation  on  the  thoracic  walls. 


CHAPTER  XYIII. 

COMPLICATIONS    OF    LABOR,    ETC. 

Rupture  of  the  Uterus.— Prolapse  of  the  Funis.— Short  Cord.— Irregular  Pre- 
sentations.— Application  of  the  Tampon. 

Ktjptuke  of  the  Uterus.— Among  the  serious  accidents 
to  wliicli  parturient  women  are  exposed  tliere  is  not  one 
more  serious  tlian  rupture  of  the  uterus.  It  is  one  of  the 
worst  complications  of  labor.  The  prognosis  in  all  cases  is 
bad.  This  accident  is  of  more  frequent  occurrence  in  mul- 
tipara, or  those  who  have  passed  through  several  labors. 
"Women  in  labor  with  the  first  child  are  not  liable  to  it. 
The  successive  enlargements  of  the  uterus  diminish  the 
strength  and  firmness  of  its  walls,  and  develop  a  tendency 
to  rupture. 

Kupture  of  the  uterus  may  occur  at  any  period  of  utero- 
gestation,  but  usually  it  takes  place  during  the  second  stage 
of  labor.  At  this  period  the  resistance  to  the  uterine  con- 
traction reaches  its  maximum.  The  head  of  the  child  en- 
gages against  the  bony  walls  of  the  pelvis  with  considera- 
ble force.  If,  now,  the  linea  ilio-jDectinea  be  abnormally 
prominent  and  labor  delayed,  the  contractions  force  the 
neck  of  the  uterus  against  this  part,  and  laceration  results. 
In  nine  cases  out  of  ten  the  rupture  starts  at  the  neck,  but 
it  may  commence  in  other  portions  of  the  uterine  walls. 


COMPLICATIONS  OF  LABOR,  ETC.  199 

Abnormal  tliinnesB  of  tlie  uterine  walls,  and  fatty  de- 
generation of  the  uterine  fibres,  are  liable  to  cause  rupture, 
if  there  is  the  slightest  over-distention  or  oTjstruction  to  the 
free  passage  of  the  head.  Great  distention  from  multiple 
foeti  or  monsters,  even  where  the  uterine  walls  are  of  normal 
thickness  and  structure,  is  an  exciting  cause. 

Deformities  of  the  pelvis,  by  obstructing  the  passage  of 
the  child,  and  increasing  the  internal  pressure  on  the  walls 
of  the  uterus,  introduction  of  the  hand  or  instruments  into 
the  uterus,  are  not  uncommon  causes.  Eupture  of  the  uterus 
may  also  arise  from  blows  on  the  abdomen,  or  from  violent 
straining  efforts. 

The  dangers  from  rupture  of  the  uterus  are  shock  or 
collapse,  haemorrhage,  peritonitis,  or  metro-peritonitis,  and 
strangulation  of  intestines. 

The  principal  and  immediate  danger  arises  from  haem- 
orrhage. The  flow  of  blood  from  dilated  vessels  of  the 
uterus  may  put  an  end  to  life  in  a  few  moments.  If  the 
contractions  of  the  uterus  continue  after  the  accident,  there 
will  be  less  danger  of  bleeding.  In  connection  with  the 
effects  of  loss  of  blood  on  the  system,  there  is -more  or  less 
danger  from  shock.  In  all  injuries  to  internal  organs  this 
peculiar  sudden  loss  of  vitality  is  present.  Sometimes  the 
loss  of  blood  is  slight,  but  the  shock  is  so  great  that  the 
patient  never  rallies. 

"When  immediate  danger  from  haemon-hage  and  shock 
has  passed,  peritonitis  or  metritis  is  apt  to  supervene.  If 
the  inflammation  of  the  peritonaeum  be  of  any  great  extent, 
if  it  involve  more  than  that  portion  covering  the  uterus,  a 
fatal  termination  may  be  expected. 

After  the  rupture  has  occurred,  a  portion  of  intestine 


200      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

may  pass  tlirougli  the  opening,  and  be  tightly  strangulated 
by  the  contracting  uterine  walls.  If  this  complication  have 
not  been  recognized  by  the  hand  in  the  uterus,  it  will  soon 
manifest  itself  by  violent  vomiting,  at  fii-st  of  the  contents 
of  the  stomach,  and  then  of  fecal  matter,  and  by  obstinate 
constipation,  pain  and  tenderness  over  the  abdomen,  and 
finally  collapse. 

At  the  time  of  rupture  the  woman  shrieks  loudly,  and 
complains  of  an  agonizing  pain  in  the  hypogastric  region. 
If  the  physician  be  near  the  bedside,  a  distinct  "  tear' "  may 
be  heard.  There  is  a  gush  of  blood  from  the  vagina,  and 
the  presenting  portion  of  the  child  immediately  recedes.  In 
many  cases  the  child  can  be  felt  in  the  abdominal  cavity 
outside  of  the  contracting  uterus.  The  patient's  coun- 
tenance becomes  excessively  anxious  and  pallid.  The  pulse 
is  rapid  and  very  feeble.  In  severe  cases  the  patient  may 
succumb  at  once.  If  the  patient  survives  the  combined 
effects  of  shock  and  hsemorrhage,  there  is  still  very  little 
chance  of  escaping  metro-peritonitis  or  other  complications 
of  the  accident. 

Treatment. — In  every  case  the  child  should  be  delivered 
at  once.  If  the  head  is  within  reach,  the  forceps  can  be 
used,  or  version  performed  to  effect  that  object.  When  the 
child  has  passed  completely  out  of  the  uterine  cavity,  Prof. 
T.  G.  Thomas,  of  this  city,  recommends  the  performance 
of  gastrotomy,  and  abstracting  the  child  through  the  open- 
ing in  the  abdomen.  He  believes  that  the  danger  to  the 
mother's  life  from  the  operation  is  not  so  great  as  when  the 
child  is  taken  out  through  the  natural  passage,  because  in 
this  latter  case  some  portions  of  the  intestine  are  almost 
certain  to  be  caught  in  the  opening  and  strangulated ;  and 


COMPLICATIONS  OF  LABOR,  ETC.  201 

also  that  an  opening  in  the  abdomen,  besides  obviating  tbis 
danger,  gives  an  opportunity  to  clean  the  cavity  of  all  blood 
or  portions  of  placenta  which  would  excite  Y^eritonitis. 
Other  authorities  recommend  the  introduction  of  the  hand 
in  all  cases  without  exception,  and  the  delivery  of  the 
child  through  the  natural  opening.  In  so  doing,  great  care 
should  be  taken  to  prevent  portions  of  the  intestine  from 
being  dragged  through  the  hole  in  the  uterus. 

Stimulants  are  to  be  freely  administered  to  counteract 
the  effects  of  the  collapse ;  styptics,  to  prevent  haemor- 
rhage, and  opiates  in  quantities  sufficient  to  relieve  pain, 
are  always  necessary. 

Pkolapse  of  the  Funis.  —  When  the  umbilical  cord 
enters  the  vagina  in  advance  of  the  child's  body,  it  is  said 
to  be  prolapsed.  If  labor  proceeds  under  such  circum- 
stances, the  cord  is  compressed  against  the  walls  of  the 
pelvis,  and  the  aerated  blood  coming  from  the  placenta 
cannot  reach  the  child.  If  this  pressure  is  maintained 
for  many  minutes,  the  child  dies  asphyxiated. 

Prolapse  of  the  funis  occurs  once  in  every  two  hundred 
and  fifty  cases  {Thomas).  It  is  caused  by  unusual  length  of 
the  cord,  sudden  escape  of  liquor  amnii,  excessive  quantity 
of  liquor  amnii,  transverse  presentations,  and  obliquity  of 
the  uterus. 

If  the  membranes  have  ruptured,  the  cord  can  be  recog- 
nized by  its  isolation  from  surrounding  structures,  and  the 
rapidity  of  its  pulsations.  The  pulsations  are  synchronous 
with  the  movements  of  the  foetal  heart. 

Treatment. — If  a  diagnosis  is  made  before  the  head  is 
engaged  in  tlie  superior  strait,  the  patient  should  be  placed 
on  her  chest  and  knees ;  the  band  of  the  attendant  should 


202      EMERGENCIES,  AND  HOW  TO  TREAT  TEEM. 

then  be  inserted  into  the  vagina,  and  the  cord  grasped  and 
gradually  returned  to  the  uterus  at  the  point  where  it  made 
its  exit.  These  efiorts  should  be  made  while  the  uterine 
fibres  are  relaxed.  The  cord  is  retained  inside  the  cervix 
by  the  finger  of  the  physician  until  the  uterus  is  firmly  con- 
tracted. The  woman  should* remain  on  her  chest  and  knees 
until  the  head  of  the  child  is  engaged  in  the  superior  strait. 

This  method  of  replacing  a  prolapsed  cord  lias  super- 
seded all  others.  It  was  first  introduced  by  Prof.  T.  G. 
Thomas,  of  this  city. 

If  the  child's  head  passes  the  superior  strait  before  the 
prolapsus  has  been  discovered,  the  forceps  must  be  applied, 
and  the  labor  completed  without  delay. 

SnoET  Cord. — ^The  length  of  the  umbilical  cord  is  sub- 
ject to  considerable  variation.  Schneider  reports  a  case  in 
which  the  cord  measured  over  three  yards,  and  Cazeaux 
speaks  of  one  which  was  only  nine  inches  in  length.  It 
usually  measures  from  eighteen  to  twenty-four  inches. 

A  short  cord  retards  the  progress  of  labor.  It  may  also 
give  rise  to  haemorrhage  by  causing  premature  separation 
of  the  placenta,  or  rupture  of  the  cord.  When  the  cord  is 
shortened  by  winding  around  the  child's  body,  similar  con- 
sequences may  ensue. 

A  short  cord  cannot  be  recognized  until  the  commence- 
ment of  labor.  At  this  time  the  fundus  of  the  uterus  will 
be  found  depressed  or  "  dimpled "  with  each  contraction. 
The  cervix  is  soft  and  dilated,  but  there  is  no  advance  in  the 
labor.  If  the  index-finger  is  applied  to  the  child's  head  it 
will  be  found  to  recede  during  the  relaxation  of  the  uterine 
fibres.  Haemorrhage  more  or  less  profuse  may  also  be 
present.    {See  Placenta  Praevia.) 


COMPLICATIONS  OF  LABOR,  ETC.  203 

Treatment. — If  the  labor  lias  not  progressed  beyond 
the  first  stage,  the  membranes  should  be  ruptured,  so 
as  to  bring  the  uterus  in  more  immediate  contact  with 
the  body  of  the  child,  and  thus  increase  its  power  of  ex- 
pulsion {Cazeaux). 

When  the  child's  head  has  passed  beyond  the  cervix, 
and  is  prevented  from  advancing  farther  by  the  short  cord, 
the  delivery  must  be  terminated  with  the  forceps.  Some 
obstetricians  advise  the  performance  of  version  as  soon  as 
the  cervix  is  dilatable. 

Ieeegitlar  Peesentations  and  Positions. — In  ordinary 
cases  of  vertex  presentations  the  occiput  rotates  anteriorly 
under  the  pubes.  Exceptionally,  it  rotates  in  a  contrary 
direction  into  the  hollow  of  the  sacrum.  In  this  position 
the  head  can  only  be  delivered  by  extreme  flexion.  In 
some  instances  the  efibrts  of  Nature  are  sufficient  to  termi- 
nate the  labor ;  the  majority  of  cases,  however,  require  the 
aid  of  the  forceps. 

"When  the  patient  is  fully  anaesthetized  and  in  position, 
the  male  blade  of  the  forcsps,  which  is  usually  held  in  the 
left  hand  of  the  operator,  is  introduced  on  the  left  side  of 
the  vagina,  and  applied  to  the  right  of  the  child's  head. 
iTie  female  blade  is  introduced  on  the  right  vaginal  wall, 
and  passed  up  to  the  left  side  of  the  head.  "When  the  for- 
ceps are  locked,  the  handles  should  be  raised  toward  the 
pubes,  in  order  to  produce  greater  flexion  of  the  head.  At 
the  same  time  traction  is  made,  and  the  head  brought  down 
to  the  vulva.  When  the  head  reaches  this  point,  some 
obstetricians  prefer  to  remove  the  forceps,  and  let  the  labor 
proceed  naturally. 

Pkesentations  of  the  Aem  ok  Leg,  together  with  the 


204:      EMERGENCIES.  AND  HOW  TO  TREAT  TDEM. 

head,  may  effectuallj  impede  the  progress  of  labor.  As  soon 
as  discovered,  efforts  should  be  made  to  return  the  pro- 
truding limbs  to  the  cavity  of  the  uterus.  Sometimes  the 
presenting  parts  are  so  firmly  wedged  in  the  pelvic  cavity, 
that  they  cannot  be  replaced ;  in  such  cases  embryotomy  or 
craniotomy  must  be  performed. 

In  Tkansveese  Pkesentations  it  is  not  unusual  for  the 
arm  and  shoulder  to  present  at  the  superior  strait.  The 
arm  should  be  replaced  and  the  head  brought  down  {ccjphalic 
version).  If  the  head  cannot  be  brought  to  the  superior 
strait,  one  of  the  lower  limbs  may  be  seized  and  the  child 
delivered  by  podalio  version.  In  the  performance  of  ver- 
sion the  following  rules  must  be  observed  :  1.  Oil  the  hack 
of  the  hand  and  fingers  only ;  2.  Introduce  the  hand  during 
the  relaxation  of  the  uterine  fibres ;  3.  Introduce  the  hand, 
which,  when  in  the  cavity  of  the  uterus  will  have  its  palmar 
surface  in  relation  with  the  anterior  portion  of  the  child's 
body;  4.  Do  not  rupture  the  membranes  until  the  hand 
has  reached  the  part  of  the  child  to  be  brought  down ;  5. 
The  necessary  manipulations  in  the  uterine  cavity  should 
be  made  between  the  pains. 

Face  Presentations  occur  once  in  two  hundred  and  fifty 
labors  {Jltomas).  The  most  frequent  position  is  the  "  right 
mento-iliac  transverse."  In  natural  labors  the  chin  is  car- 
ried forward  under  the  pubes  and  is  finally  delivered  by  a 
process  of  flexion.  Should  the  chin  rotate  posteriorly  into 
the  hollow  of  the  sacrum,  the  longest  diameter  of  the 
child's  head  (occipito-mental)  is  brought  in  relation  with 
the  antero-posterior  diameter  of  the  pelvis.  The  former 
measures  five  inches  and  a  quarter,  the  latter  four  inches 
and  a  quarter.     It  is  impossible,  therefore,  for  the  labor 


COMPLICATIONS  OF  LABOR,  ETC.  205 

to  terminate  naturally.     Operative  procedures  are  always 
necessary. 

Treatment. — If  a  diagnosis  is  made  before  the  liead  is 
engaged,  the  face-presentation  may  be  converted  into  one 
of  the  vertex  by  flexing  the  head.  If  this  cannot  be  done,  an 
attempt  should  be  made  to  change  the  position  of  the  face 
and  rotate  the  chin  under  the  pubes.  Either  the  hand  of 
the  physician  or  the  vectis  may  be  employed  for  this  pur- 
pose. "When  the  movement  of  rotation  cannot  be  accom- 
plished, the  perinseum  may  be  incised  and  the  child  delivered 
by  means  of  forceps.  This  method  is  recommended  by 
Dr.  Taylor.  Other  authorities  advise  craniotomy  when 
milder  measures  fail. 

AppLicATioisr  OF  THE  Tampon. — The  tampon  is  employed 
for  the  suppression  of  haemorrhage  occurring  in  abortion, 
placenta  prsevia,  ulceration  and  laceration  of  the  vaginal 
walls,  etc.  It  should  not  be  resorted  to  in  jpost-jpartum 
haemorrhage. 

The  tampon  may  be  made  of  sponge,  picked  lint,  cot- 
ton, India-rubber  bags  filled  with  water  or  ice,  or  a  surgi- 
cal roller-bandage.  The  latter  was  first  employed  in  tam- 
poning by  Prof.  I.  E.  Taylor.  He  claims  that  the  bandage 
is  more  readily  introduced  and  removed  than  any  other  ma- 
terial. 

Any  of  the  substances  employed  may  be  wet  in  astrin- 
gent solutions  previous  to  their  introduction.  The  operation 
is  performed  with  or  without  a  speculum.  The  patient 
should  be  placed  in  the  recumbent  posture  and  the  thighs 
flexed  on  the  abdomen  and  abducted.  A  speculum  is  then 
introduced  into  the  vagina,  and  the  lint  or  other  materials 
passed  up  and  packed  tightly  around  and  upon  the  cervix, 


OQQ  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

increasing  the  quantity  until  the  vagina  is  completely  filled. 
A  T-bandage  is  afterward  employed  to  maintain  the  tam- 
pon in  position.  The  tampon  should  he  changed  at  the  end 
of  twenty-four  or  thirty-six  hours. 

"When  the  patient  desires  to  micturate,  a  portion  of  the 
plug  at  the  entrance  of  the  vagina  must  be  removed.  At 
this  point  tlie  plug  presses  on  the  urethral  canal,  and  its 
removal  is  necessary  before  the  urine  can  pass  through. 


CHAPTEE  XIX. 

RETENTION  OF  URINE.— DISLOCATION  OF  THE  NECK— INJURIES 
FROM  LIGHTNING.— COLIC. 

Retention  of  Ukeste. — detention  of  urine  may  arise 
from  spasmodic  contraction  of  the  muscular  fibres  of  the 
neck  of  the  bladder,  organic  stricture  of  the  urethra,  en- 
larged prostate,  stone  in  the  bladder,  paralysis  of  the  blad- 
der, abscesses  in  the  perinseum,  fracture  of  the  pubic  bones, 
with  laceration  of  the  urethra,  and  injuries  to  the  spinal 
cord. 

Ketention  which  is  produced  by  spasm  of  the  muscular 
fibres  accompanies  exposure  to  cold,  or  acute  inflammation 
of  the  urethra.  It  occurs  suddenly,  and  is  not  connected 
with  chronic  disease  of  the  genitals.  There  is  pain  in  the 
perinseum  and  hypogastric  region.  If  the  bladder  is  dis- 
tended with  urine,  a  large  area  of  dulness  will  be  found  on 
percussing  along  the  pubes.  Febrile  excitement  is  also  pres 
ent  if  the  retention  follows  inflammation. 

The  patient  is  readily  relieved  by  the  application  of  hot 
fomentations  over  the  hypogastrium  and  genitals,  hot  baths, 
and  by  the  internal  administration  of  opium.  Leeches  to 
the  perinseum  are  useful  in  some  cases. 

In  retention  from  organic  stricture  the  patient  will  have 


20S  EMERGEXCIES,  AND  HOW  TO  TREAT  THEM. 

hadj  for  a  variable  period  previous  to  tlie  attack,  great  diffi- 
culty in  micturition,  a  small,  twisted  stream  of  urine,  and 
some  degree  of  pain.  An  exploration  with  sounds  or  bougies 
M-ill  show  an  obstruction  at  some  point  between  tlie  meatus 
and  membranous  portion  of  the  urethra. 

If  the  stricture  cannot  be  dilated  rapidly,  and  if  the 
condition  of  the  patient  will  not  permit  of  urethrotomy,  the 
distended  bladder  may  be  temporarily  relieved  by  punctur- 
inc  throuo;h  the  rectum.  At  the  base  of  the  bladder  there 
is  a  space  uncovered  by  peritonceum,  which  is  bounded  on 
each  side  by  the  vesiculse  seminalis,  behind  by  the  recto- 
vesical fold  of  the  peritonreum  and  in  front  by  the  prostate 
gland.  The  operation  at  this  point  is  performed  by  insert- 
ing the  left  index-finger  into  the  rectum  and  carrying  it 
half  an  inch  or  an  inch  beyond  the  prostate,  and  then  in- 
troducing a  large,  curved  trochar  (using  the  finger  as  a 
guide)  and  plunging  it  into  the  bladder  at  that  point.  The 
stylet  is  then  removed,  and  the  urine  escapes  through  the 
canula.  If  fluctuation  cannot  be  detected  by  the  finger,  the 
operation  should  not  be  performed. 

Retention  from  enlarged  prostate  occurs  in  advanced  life. 
The  hypertrophied  gland  may  be  felt  by  a  rectal  examina- 
tion. If  the  ordinary  large  curved  prostatic  catheter  can-  • 
not  be  passed  over  the  obstruction,  an  instrument  W'ith  a 
shorter  curve  may  be  forced  through  the  enlarged  lobe  into 
the  bladder,  or  the  bladder  may  be  opened  through  the  rec- 
tum in  the  manner  previously  described. 

Habitual  distention  of  the  bladder  may  induce  a  semi- 
paralytic  condition  of  the  walls  of  the  organ  and  produce 
retention.  This  condition  occurs  not  unfrequently  in  females 
whose  opportunities  for  emptying  the  bladder  are  often  re- 


DISLOCATION  OF  THE  NECK— INJURIES  FROM  LIGHTNING.    200 

stricted.     It  is  relieved  by  frequent  introduction   of  tlie 
catheter,  cold  Lip-batlis,  and  tonics. 

When  retention  arises  from  injuries  to  the  spinal  cord 
the  bladder  should  be  emptied  twice  each  day  by  means 
of  a  catheter,  and  thoroughly  washed  after  the  urine  is 
evacuated. 

Dislocation  of  the  Neck. — ^This  accident  is  usually 
fatal.  In  death  from  hanging  the  transverse  ligament  is 
ruptured,  the  axis  is  dislocated  from  the  atlas,  and  the 
odontoid  process  of  the  former  bone  presses  upon  the 
upper  portion  of  the  cord.  Death  in  such  a  case  is 
almost  instantaneous. 

Partial  dislocations  of  the  cervical  vertebra  lower  down 
are  sometimes  recovered  from.  In  these  cases,  the  head  is 
turned  to  one  side,  and  there  may  be  slight  paralyses  below 
the  point  of  injury. 

Treatment. — The  surgeon  grasps  the  head  of  the  patient, 
while  an  assistant  steadies  the  shoulders.  Extension  is 
then  carefully  made,  while  the  head  is  rotated  toward  its 
normal  situation.  Perfect  rest  for  a  few  days  is  afterward 
necessary. 

Injuries  feom  Lightning. — The  effects  of  lightning  on 

the  system  vary  in  character.     In  some  instances  death  is 

instantaneous,   in    others  there  is  more  or  less  extensive 

charring  of  the  tissues,  paralysis  of  the   extremities,  loss 

of  sight,  speech,   and  hearing,  and  haemorrhage  from  the 

mucous  canals.     Burns  produced  by  lightning  are  apt  to 

run  a  protracted  course,  and  are  accompanied  by  extensive 

suppuration.    Paralysis  is  rarely  recovered  from.     Boudin 

speaJ&s  01   cases  where  persons  injured  by  lightning  had 

images   of  surrounding  objects  depicted  on  the  body  and 
14 


210      EMERGENCIES,  AXD  HOW  TO  TREAT  THEM. 

clotlies.  Similar  curious  occurrences  liave  been  recorded 
by  other  observers. 

The  symptoms  presented  by  a  patient  suffering  from  a 
lightning-stroke  are  coldness  of  the  extremities,  sighing  res- 
piration, absence  of  radial  pulse,  and  insensibility. 

After  death  the  ordinary  rigor  mortis  is  not  witnessed, 
and  the  blood  is  said  to  be  more  fluid  than  in  death  from 
other  causes. 

The  treatment  consists  in  friction  to  the  surface,  artifi- 
cial respiration,  and  the  administration  of  stimulants. 

Colic. — Spasmodic  contraction  of  the  muscular  walls  of 
the  intestines  is  generally  attended  with  great  pain.  It  is 
occasioned  by  cold,  or  over-indulgence  in  indigestible  food. 
It  is  characterized  by  paroxysms  of  intense  pain  over  the 
abdomen ;  vomiting  is  sometimes  associated  with  it.  The 
pain  is  distinguished  from  that  accompanying  inflamma- 
tion by  the  fact  that  it  is  relieved  on  pressure. 

An  injection  of  one  or  two  quarts  of  very  warm  water 
and  an  opiate  will  cure  it.  The  following  prescription 
answers  in  many  cases : 

J5.   Bismuthi  subnitratis 3j. 

MorphiiB  sulphatis gr.j.    M. 

Ft.  pulv.  X. 

One  powder  should  be  given  every  hour  until  the  patient 
is  relieved.  Mustard  or  hot  flax-seed  poultices  may  also  be 
applied  over  the  abdomen.     {See  Lead  Colic.) 


CHAPTEE  XX. 

TOXICOLOGY. 
NAECOTIC  rOISONS. 

Op'um,  Belladonna,  Hyoscyamus,  Aconite,  Tol)acco,  Stramonium,  Chloroform, 
Hemlock,  Lobelia,  "Woorara,  Ether,  Alcohol,  etc. 

Opium  is  obtained  from  the  unripe  capsules  of  the  Pctpci- 
ver  somniferum,  or  poppy.  The  juice  of  the  capsules  is  the 
portion  used.  The  plant  is  cultivated  in  India,  Persia, 
Europe,  and  in  this  country.  It  has  been  employed  as  a 
medicine  from  the  time  of  Hippocrates  to  the  present  day, 
and  stands  unrivalled  as  a  remedy  for  the  alleviation  of 
pain. 

In  Tm'key  and  China  the  drug  is  habitually  smoked 
and  chewed.  In  the  western  parts  of  Europe  and  in  this 
country  the  habit  of  smoking  and  eating  opium  is  not  un- 
common. It  engenders  exaltation  of  ideas,  and  general 
buoyancy  of  spirits.  Some  of  the  brightest  lights  of  the 
literary  world  have  fallen  victims  to  this  vile  habit  of 
opium-eating.  The  well-known  case  of  Fitz-Hugh  Ludlow 
is  familiar  to  most  American  readers,  and  in  England  the 
celebrated  Coleridge  and  De  Quincy  were  victims  to  the 
drug. 

The  quantity  of  opium  necessary  to  cause  death  varies 
with  circumstances.     Quantities  which  would  destroy  life 


212      EMERGENCIES,  AND  HOW  TO  TREAT  TUEM. 

in  ordinary  cases  are  eaten  with  perfect  impunity  by  persons 
accustomed  to  its  daily  use.  Enough  has  been  taken  at  a 
dose  to  destroy  a  dozen  lives.  Ilerdouin  mentions  the  case 
of  a  woman  with  cancer  of  tlie  uterus  who  took  laudanum 
by  pints.  De  Quincy  was  in  tlic  habit  of  taking  nine  ounces 
daily.  I  have  known  two  cases  average  daily  from  four  to 
six  ounces. 

The  amount  which  will  destroy  life  depends  also  on  the 
age  of  the  person.  Infants  can  bear  but  a  very  minute 
quantity.  One  drop  of  laudanum  has  been  known  to  kill  a 
child.  Children  are  extremely  susceptible  to  its  influence. 
The  smallest  quantity  known  to  have  destroyed  the  life 
of  an  adult  is  two  drachms  of  laudanum  (Skae).  In  the 
majority  of  cases  larger  quantities  are  required.  Opium 
kills  in  from  four  to  twelve  hours. 

Some  animals  are  scarcely  affected  by  the  drug.  On 
apes  it  exerts  no  perceptible  eflfect.  In  one  instance  five 
Imndred  grains  were  given  to  one  of  those  animals  without 
injury. 

Tests. — Perchloride  of  iron  gives  a  red  precipitate  with 
solutions  of  opium  which  contain  meconic  acid.  ]^itric  acid 
gives  a  red  precipitate  with  morphia,  the  principal  alkaloid 
of  opium. 

The  symptoms  manifested  in  persons  addicted  to  opium- 
eating  are  readily  recognized.  The  face  is  sallow,  pinched, 
and  parchment-like.  The  eyes  are  sunken  and  glassy. 
"When  they  are  deprived  of  the  drug  there  is  an  unsteady, 
trembling  gait,  great  depression  of  spirits,  and  intense 
mental  and  physical  agony.  While  under  treatment  pa- 
tients endeavor  by  every  conceivable  means  to  obtain  a  dose, 
even  getting  down  on  their  knees,  begging  piteously  for  it. 


NARCOTIC  POISONS.  213 

But  in  sucli  cases  it  is  rarely  expedient  to  satisfy  their 
cravings.  "  Tapering  off,"  as  tliey  call  it,  will  not  result  in 
cure.  The  appetite  for  the  drug  remains  so  long  as  they 
are  allowed  to  taste  and  experience  its  intoxicating  effects. 
Large  doses  of  bromide  of  potassium  will  do  much  in  these 
cases  to  diminish  the  craving. 

The  effects  of  poisonous  doses  of  opium  appear  in  from 
thirty  minutes  to  two  hours  from  its  administration.  Liquid 
preparations  of  opium,  and  the  salts  of  morphia,  act  very 
rapidly.  The  patient  trembles,  becomes  giddy,  drowsy, 
and  unable  to  resist  the  tendency  to  sleep.  Gradually  the 
stupor  deepens,  until  there  is  perfect  insensibility.  The 
pupils  are  contracted,  eyes  and  face  congested ;  the  pulse, 
at  first  rapid  and  small,  is  now  slow  and  feeble.  A  marked 
diminution  in  the  number  of  respiratory  movements  is 
discernible.  From  twenty  per  minute  they  run  down  to 
twelve,  or  even  eight.  The  breathing  is  stertorous.  A 
profuse  perspiration  breaks  out  on  the  surfaces.  As  coma 
deepens,  and  death  approaches,  the  extremities  become 
cold,  and  the  sphincters  relaxed.  Occasionally  the  odor  of 
opium  may  be  noticed  in  the  breath,  and  in  such  a  case  the 
diagnosis  is  materially  assisted. 

The  following  singular  case  of  opium-poisoning  in  con- 
junction with  cholera  illustrates  the  characteristic  effects  of 
the  drug : 

A  colored  woman  was  admitted,  in  tbe  summer  of  1866, 
to  the  pavilion  attached  to  Bellevue  Hospital ;  she  was  suffer- 
ing from  a  bad  attack  of  Asiatic  cholera,  and  when  brought  to 
the  ward  was  fast  approaching  a  state  of  collapse.  Inquii'ing 
into  her  history,  she  stated  that  the  attack  came  on  four 
hours  previous,  and  while  at  tlie  station-house  half  an  houi 


214  EMERGENCIES,   AND   UOW   TO   TREAT   THEil. 

before  her  admission  a  policeman  liad  given  lier  a  table- 
spoonfiil  of  pure  laudanum.  As  there  were  no  symptoms  to 
corroborate  licr  story,  I  did  not  credit  it  and  left  her.  In 
about  three-quarters  of  an  hour  the  nurse  in  charge  informed 
me  tliat  the  patient  was  insensible,  and  could  not  be  roused 
to  take  her  medicine.  I  went  down  immediately  and  found 
the  patient  as  the  nurse  had  stated,  in  a  comatose  condition. 
The  pupils  were  contracted,  respiration  down  to  eight  per 
minute.  Pulse  slow  and  small.  Injections  of  brandy  and 
ammonia,  and  strong  coflee,  were  ordered.  The  body  was 
properly  stripped,  and  flagellation  applied  with  twisted 
towels.  After  two  hours  of  this  treatment  signs  of  con- 
sciousness appeared.  The  patient  was  then  lifted  from  the 
bed  and  rapidly  marched  up  and  down  the  ward,  supported 
by  her  nurses  until  she  was  fully  restored.  Five  hours  were 
spent  in  bringing  this  woman  to  a  state  of  consciousness. 

The  treatment  for  opium-poisoning,  and  the  opium  it- 
self, seemed  to  exert  a  curative  effect  on  the  cholera,  and 
the  patient  was  discharged  three  days  after  her  admission, 
cured. 

Treatment. — If  the  patient  is  seen  soon  after  the  poi- 
son has  been  taken,  the  stomach  should  be  emptied  by  a 
stomach-pump  or  emetics.  Twenty  grains  of  zinc,  or 
ipecac,  a  tablespoonful  of  mustard  or  common  salt,  will 
suffice  to  eject  the  poison.  These  medicines  should  be  fol- 
lowed by  copious  draughts  of  warm  water  to  keep  up  the 
vomiting.  As  soon  as  the  stomach  is  emptied,  belladonna, 
the  physiological  antidote  for  opium,  may  be  tried.  The 
active  principle  of  belladonna  {atrapia)  may  be  given  by 
hypodermic  injections.  A  solution  of  one  grain  to  the 
ounce  is  made,  and  lifteen  or  twenty  minims  injected,  and 


NARCOTIC  POISONS.  215 

repeated,  if  necessary.  Strong  coffee  is  another  antidote. 
In  all- cases  the  antidotes  should  be  accompanied  by  stimu- 
lants. Brandy  and  ammonia  may  be  frequently  given  by 
the  mouth  or  rectum.  Flagellation  of  the  surface  by  the 
hands  or  towels,  and  causing  the  patient  to  walk  about, 
are  important  aids  to  restoration. 

The  use  of  the  Faradic  current  will  be  of  service  in  all 
cases.  The  electrodes  may  be  applied  over  the  phrenic 
nerve  and  diaphragm,  and  over  the  frontal  bone. 

BELLADOJSTNA. 

The  leaves  and  root  of  Atropa  helladonna,  or  deadly 
nightshade,  are  largely  employed  for  medicinal  purposes. 
All  parts  of  the  plant  possess  poisonous  qualities.  The 
leaves  and  berries  are  frequently  eaten  by  children,  and 
with  deleterious  effects.  Thirty -six  berries  have  produced 
death  in  a  child.  An  infusion  made  from  two  drachms 
of  the  leaves  has  killed  an  adult.  Atropia,  the  active 
principle  of  the  plant,  given  in  two-grain  doses,  has  proved 
fatal. 

The  first  symptoms  of  poisoning  are  dryness  of  the 
throat,  constriction  of  the  tauces,  difficult  deglutition,  indis- 
tinct vision  {am'blyoj>ia),  or  double  vision  {dij)loj>ia),  head- 
ache, staggering,  and  confusion  of  ideas,  stammering,  etc. 
The  pupils  are  widely  dilated,  face  suffused,  lips  livid,  and 
pulse  rapid  and  intermittent.  Delirium  and  deep  coma 
soon,  supervene,  followed  rapidly  by  death.  In  a  few  cases 
there  are  convulsions. 

After  death  putrefaction  rapidly  ensues.  Large  purple 
Bpots  form  on  the  body.  There  may  be  signs  of  inflamma- 
tion in  the  stomach  and  intestines. 


210      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Treatment. — An  emetic  sliould  be  administered  without 
delay,  and  repeated  imtil  the  stomach  is  completely 
emptied.  This  sliould  be  followed  by  stimulation,  friction 
to  the  extremities,  and  warmth.  Some  recommend  opium 
as  an  antidote.  It  has  been  successful  in  one  or  two  cases. 
Runge  advocates  the  use  of  lime-water  in  large  quantities 
as  a  neutralizer  of  the  poison.  Bouchard  has  employed  the 
ioduretted  iodide  of  potassium  with  benefit.  All  the  strong 
alteratives  are  said  to  possess  more  or  less  remedial  j^ower ; 
but  experiments  have  not  proved  their  efficacy. 

Brandy  by  enema,  and  opium  by  hypodermic  injection, 
in  conjunction  with  large  doses  of  lime-water,  constitute  the 
most  reliable  remedies  that  have  yet  been  fixed  upon.  If 
the  coma  appear  rapidly  and  without  convulsive  move- 
ments, electricity  may  be  used  with  benefit,  and  cold  water 
may  be  poured  on  the  chest  and  face. 

HEMLOCK. 

There  are  five  varieties  of  hemlock  which  possess  poison- 
ous properties,  viz.,  Conium  onaculatum,  Cicuta  mrosa^ 
(Enanthe  crocata,  Phellandrium  aquaticum^  and  JEthusa 
cynajpium.  Conium  maculatum,  or  spotted  hemlock,  is  much 
used  for  medicinal  purposes.  It  was  a  prej^aration  of  this 
drug  which  caused  the  death  of  the  philosopher  Socrates. 
All  parts  of  the  plant  are  poisonous.  To  inhale  the  air  in 
the  vicinity  of  this  plant  in  the  hot  months  of  summer  is 
said  to  be  followed  by  slight  narcotism.  Its  poisonous 
effects  are  manifested  within  half  an  hour  after  entering  the 
stomach,  and  death  results  in  from  one  to  three  hours. 

The  symptoms  are  dryness  of  the  throat,  muscular  trem- 
ors, dizziness,  difficult  deglutition,  and  a  feeling  of  great 


NAKCOTIC  POISONS.  21Y 

prostration  and  faintness.  The  limbs  are  rendered  power- 
less, sometimes  being  completely  paralyzed.  The  pupils 
are  dilated,  the  pulse  is  rapid  and  small.  Deep  insensi- 
bility rapidly  supervenes,  and  there  may  be  convulsions 
preceding  the  fatal  termination. 

The  roots  of  Cicuta  virosa^  or  water-hemlock,  are  some- 
times mistaken  for  parsnips,  and  eaten  in  large  quantities. 
The  symptoms  of  poisoning  resemble  those  of  the  preceding 
variety,  with  the  addition  of  vomiting,  and  pain  in  the  epi- 
gastrium ;  convulsions  are  also  more  frequent. 

The  leaves  and  roots  of  the  (Enanthe  crocata  are  more 
deadly  than  any  other  species  of  hemlock.  The  plant  grows 
at  the  sides  of  ditches  and  other  moist  places  ;  it  resembles 
celery. 

When  taken  internally,  it  always  produces  violent  and 
protracted  convulsions,  in  conjunction  with  the  symptoms 
previously  enumerated  {Taylor). 

jEthuaa  cyna^ium,  or  fool's  parsley,  does  not  kill  so 
rapidly  as  the  other  varieties.  It  resembles  ordinary  pars- 
ley, and  is  sometimes  eaten  by  mistake.  The  symptoms 
commence  by  intense  pain  in  the  abdomen,  followed  by 
vomiting  and  purging,  and  a  tendency  to  coma. 

Treatment. — Empty  the  stomach  of  its  contents,  and  use 
diffusible  stimulants  in  large  quantities.  If  there  are  much 
pain  and  vomiting,  bromide  of  potassium,  in  ten-grain 
doses,  may  be  given  at  short  intervals. 

HTOSCTAMUS. 

Hyoscyamus  niger^  or  henbane,  is  a  European  plant, 
cultivated  in  this  country.  The  leaves  and  seeds  are  largely 
employed  in  medicine.   All  parts  of  the  plant  are  poisonous. 


213     EMERGENCIES,  AND  HOW  TO  TREAT  THEM 

The  seeds  are  more  powerful  than  other  parts.  Its  alkaloid 
{hyoscyamia)  is  a  deadly  poison  taken  in  minute  quantities. 
Animals,  such  as  horses,  goats,  cows,  etc.,  are  exempt  from 
its  injurious  influences,  and  eat  it  without  receiving  harm. 
Dogs  and  cats  are  soon  killed  by  it. 

Poisonous  doses  of  the  seeds  or  leaves  are  followed 
rapidly  Ly  dilatation  of  the  pupils,  dimness  of  vision,  mus- 
cular twitchings,  inability  to  articulate  plainly,  and  a  ten- 
dency to  sleep.  In  a  later  stage  there  are  vomiting  and 
purging,  abdominal  pain,  delirium,  convulsive  movements 
of  the  extremities,  small,  intermittent  pulse,  and  coma, 
which  is  often  followed  by  death. 

A  post-mortein  examination  shows  evidences  of  inflam- 
matory action  in  the  stomach  and  intestines,  and  in  a  few 
cases  congestion  of  the  brain. 

Treatment. — Common  charcoal  has  been  strongly  recom- 
mended as  an  antidote  by  Dr.  Gar.  The  substance  lapidly 
absorbs  the  alkaloid  upon  which  the  poisonous  properties  of 
the  plant  depend,  and  prevents  its  peculiar  action.  Solu- 
tions of  caustic  alkalies  are  said  to  neutralize  the  poison. 
In  every  case  stimulants  should  be  employed,  as  in  the  other 
varieties  of  poisoning. 

ACONnE. 

This  drug  is  obtained  from  the  leaves  and  root  of  the 
Aconitum  napeUus  (monk's-hood,  or  wolfsbane).  Prepara- 
tions of  the  leaves  and  root  are  used  in  medicine.  The  root 
is  said  to  have  ten  times  greater  strength  than  the  leaves. 
The  plant  lias  been  mistaken  for  horseradish.  In  small 
doses  it  acts  as  an  arterial  sedative,  diminishing  the  heart's 
action,  and  lowering  the  pulse.     It  differs  from  all  other 


NARCOTIC  POISONS.  219 

narcotic  medicines  in  producing  a  peculiar  numbness  and 
tingling  sensation  in  tlie  mouth  and  fauces. 

Cases  of  poisoning  generally  result  from  careless  over- 
dosing witli  the  tincture  of  the  root.  Thirty  drops  of  Flem- 
ming's  tincture  have  caused  death,  but  there  are  instances 
of  a  drachm  or  two  having  been  taken  by  mistake  without 
fatal  results.  The  active  principle  (aconitia)  is  one  of  the 
most  active  poisons  known  ;  one-twelfth  of  a  grain  has 
proved  fatal. 

Poisonous  doses  produce  immediately  the  characteristic 
numbness  and  tingling  of  the  mouth  and  fauces.  The  same 
feeling  is  experienced  in  the  extremities.  There  are  sore- 
throat,  pain  over  the  stomach,  and  vomiting.  The  pulse  is 
extremely  weak  and  compressible.  The  pupils  are  in  some 
cases  dilated,  at  others  contracted.  As  in  poisoning  by 
other  narcotics,  there  are  dimness  of  vision,  vertigo,  great 
prostration,  general  loss  of  sensibility,  delirium,  and  coma. 
Death  is  said  to  take  place  from  syncope,  asphyxia,  and 
coma. 

Treatment. — Emetics  are  first  employed.  Complete 
evacuation  of  the  stomach  is  sometimes  all  that  is  required. 
Brandy  in  tables]50onful  doses,  given  in  ice-water  every 
half-hour,  is  a  useful  method  of  stimulation.  Preparations 
of  nux-vomica  are  said  to  neutralize  the  action  of  aconitia. 
The  tincture  of  nux-vomica  has  been  used  with  apparent 
benefit.  It  may  be  given  in  ten-drop  doses,  every  fifteen 
minutes,  until  the  alarming  symptoms  have  subsided. 

TOBACCO. 

This  plant  was  first  discovered  in  America  by  the 
Spaniards.     The  English  are  indebted  to  Sir  "Walter  Pa- 


220      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

leisli  for  furnisliino:  them  with  the  "weed."  The  leaves 
are  employed  medicinally  as  poultices  to  painful  swellings, 
and  for  their  emetic  properties.  Five  grains  of  the  powder 
will  produce  emesis.  In  the  form  of  snuff  it  has  been 
employed  by  keepers  of  immoral  houses  to  drug  their  vic- 
tims. A  teaspoonful  of  snuff  in  a  glass  of  ale  will  give  rise 
to  delirium,  vomiting  and  purging,  and  faintness.  The 
active  principle  {nicotia)  is  a  deadly  poison.  One  drop  will 
kill  a  rabbit  {Taylor).  It  causes  death  in  two  or  three 
minutes. 

Tlie  effects  produced  in  persons  of  nervous  temperament 
by  long-continued  use  of  tobacco  are  well  marked.  An 
examination  of  the  heart  shows  that  it  is  intermittent  in  its 
action,  and  its  pulsations  more  rapid  than  normal.  The 
pulse  is  weak.  Shortness  of  breath  and  palpitation  of  the 
heart  are  complained  of  in  going  up-stairs.  Slight  excite- 
ment induces  great  tremulousness.  There  is  often  impair- 
ment of  the  mental  faculties,  such  as  defective  memory,  etc. 
The  countenance  has  a  sallow  aspect.  Some  impairment 
of  the  digestive  functions  is  almost  always  present. 

The  effects  of  large  quantities  of  tobacco  on  the  system 
are  well  known  to  smokers  and  chewers.  Early  efforts  in 
acquiring  the  habit  are  characterized  by  poisonous  symp- 
toms. There  are  intense  nausea  and  vomiting.  The  nausea 
is  said  to  resemble  that  occurring  in  sea-sickness.  Yertigo, 
muscular  weakness,  and  intense  prostration  verging  on  syn- 
cope, are  also  present.  Later  the  extremities  become  cold 
and  clammy,  and  convulsions  sometimes  precede  death. 

Treatment. — Hot  bottles  and  blankets  should  be  applied 
to  the  body.  Brandy  by  enema  is  always  required  if  the 
liquid  cannot  be  retained  on  the  stomach.     Sub-nitrate  of 


NARCOTIC  rOISONS,  221 

bismuth  in  ten-grain  doses,  continued  with  one-fifteenth  of 
a  grain  of  morphia,  will  do  much  to  allay  the  distressing 
nausea. 

DIGITALIS 

Is  a  product  of  the  Digitalis  jyurjpurea,  or  purple  fox- 
glove. It  exerts  a  powerful  sedative  effect  upon  the  heart, 
acts  on  the  kidneys  as  a  diuretic,  and  on  the  brain  as  a  nar- 
cotic. Some  ascribe  its  influence  in  diminishing  the  pulsa- 
tions of  the  heart  in  febrile  diseases  to  a  stimulating  effect 
on  the  heart's  fibres,  which  gives  them  renewed  vigor. 

It  is  dangerous  on  account  of  its  accumulative  effect. 
It  may  be  administered  for  several  days  without  apparent 
action  of  any  kind,  when  suddenly  the  patient  is  prostrated 
with  all  the  symptoms  characterizing  poisoning  by  this 
drug.  The  alkaloid  digitalia,  v^hen  boiled  with  sulphuric 
acid,  is  changed  into  glucose,  or  grape-sugar  {Kinsman). 

The  symptoms  produced  by  poisonous  doses  are  loss  of 
strength,  feeble  and  fluttering  pulse,  faintness,  nausea  and 
vomiting,  and  stupor.  The  body  is  bathed  in  cold  perspira- 
tion, the  pupils  are  dilated,  the  breathing  is  sighing  and 
irregular,  and  convulsions  are  sometimes  present. 

Treatment. — Ammonia,  given  internally  in  frequently- 
repeated  doses,  is  an  admirable  remedy,  when  the  patient  is 
in  a  state  of  syncope.  The  medicine  should  also  be  applied 
to  the  nostrils.  Brandy  internally,  and  warmth  to  the  sur- 
face, are  followed  by  good  results. 

steamoxxitm:. 
The   common  name   of    the  plant    is  thorn-apple,  or 
Jamestown  weed.     It  grows  all  over  this  country,  particu- 
larly along  the  roadsides  and  in  moist  grounds.  All  parts  of 


222      EMERGEXCIES,  AND  EOW  TO  TREAT  THEM. 

tlie  plant  are  poisonous.  The  seeds  are  not  unfrequent'iy 
eaten  by  cliildren.  These  seeds  are  recognized  by  their 
dark,  ahnost  bhick  color,  their  flat,  roughened  surface,  and 
kidney-shape.  The  drug  is  much  used  in  asthma  and  other 
spasmodic  affections.  Cigarettes  made  of  the  leaves  are 
smoked  by  asthmatics  with  great  relief.  The  active  prin- 
ciple (daiuria),  given  in  small  doses,  proves  rapidly  fotal. 

The  symptoms  of  poisoning  are  dryness  of  the  throat, 
thirst,  delirium,  convulsive  movements,  swelling  of  the  face, 
dilatation  of  the  pupil,  suffusion  of  the  eyes,  small,  rapid 
pulse,  hurried  breathing,  and  hot  skin.  In  some  cases  there 
are  pain  over  the  stomach,  and  vomiting.  Convulsions  are 
nearly  always  present,  and  are  liable  to  be  mistaken  for 
those  arising  from  uriemia  or  epilepsy.  On  examination  of 
the  vomited  matters,  the  seeds  of  stramonium  will  probably 
be  discovered,  which  will  make  the  diagnosis  clear. 

Treatment — Opium,  stimulants,  and  alkaline  medicines 
are  employed  in  the  same  manner  as  after  poisoning  by 
belladonna. 

LOBELIA   INFLATA 

Is  used  in  medicines  as  an  emetic  and  antispasmodic. 
The  common  name  is  ludian  tobacco.  It  is  often  adminis- 
tered by  quacks  who  style  themselves  "  vegetable  doctors," 
and  is  sometimes  given  in  dangerous  doses.  Taylor  recites 
several  cases  where  death  resulted  from  improper  quantities 
administered  by  those  men. 

In  large  doses  it  induces  excessive  vomiting  and  purging, 
pain  in  the  bowels,  contraction  of  the  pupils,  delirium, 
coma,  convulsions,  and  death. 

The  post-morUni  appearances  consist  in  congestion  of 


NARCOTIC  POISONS.  223 

the  membranes  of  the  brain,  and  evidences  of  inflammation 
of  the  stomach  and  intestinal  canal. 

The  treatment  is  confined  to  stimulants,  and  counter- 
irritation  over  the  stomach. 

C00CULU8   INDIOUS 

Contains  a  peculiar  active  principle,  called  ^icrotoxia,  to 
which  its  poisonous  character  is  due.  The  drug  is  some- 
times given  to  certain  kinds  of  fish  in  India  to  render  their 
capture  an  easy  matter.  The  seeds  are  small,  and  about 
the  size  of  a  pin-head.  The  active  principle  is  said  by 
Glover  to  produce  the  same  class  of  convulsive  movements 
witnessed  after  lesions  of  the  corpora  quadrigemina  and 
cerebellum,  viz.,  tonic  spasms,  and  wheeling  and  backward 
movements  of  the  body. 

The  symptoms  and  treatment  are  the  same  as  in  other 
varieties. 

MUSHROOMS. 

This  plant  is  eaten  in  large  quantities  in  all  parts  of  the 
civilized  world.  There  are  numerous  varieties  of  the  plant, 
some  harmless  in  their  nature,  and  others  highly  poisonous. 
Strangely  enough,  many  which  are  regarded  as  deleterious 
in  one  part  of  the  world  are  eaten  with  impunity  in  others. 
Mushrooms  which  are  considered  dangerous  in  England  and 
in  this  country,  are  used  as  food  in  Eussia ;  and  some  which 
are  eaten  in  England  are  thought  poisonous  at  Home. 

The  poisonous  mushrooms  may  be  recognized,  according 
to  Chrystosin  and  M.  Richaud,  by  their  dark  color,  acid, 
bitter  taste,  pungent  odor,  and  by  the  fact  that  they  gener- 
ally  grow  in  damp,  dark  place^^i 


224  EMERGENCIES,  AND  HOW  TO  TREAT   THEM. 

When  a  poisonous  mushroom  is  taken  internally,  it 
causes  extreme  muscular  weakness,  Tertigo,  mental  halluci- 
nations, stupor,  and  in  a  few  instances  violent  vomiting  and 
purging.  Tiecoverj  is  not  unfrequent,  even  when  large 
quantities  have  been  eaten. 

Treatment. — The  stomach  and  bowels  should  be  acted 
upon  by  emetics  and  cathartics,  -svhere  vomiting  and  purging 
are  absent.  Castor-oil,  however,  may  be  given  in  all  cases. 
Opiates  are  recommended  by  some  where  there  is  much 
delirium  without  stupor.  Ether  has  been  used  with  benefit. 
If  the  prostration  is  great,  the  free  nse  of  diluted  stimulants 
will  be  necessary. 

TEW-TKEES. 

The  leaves  and  berries  of  this  tree  are  extremely  poison- 
ous. An  infusion  of  the  leaves  is  often  administered  in  this 
country  to  bring  on  the  menstrual  flow,  or  to  produce 
abortion.  Its  action  in  this  respect  is  not  well  understood. 
Children  are  often  poisoned  by  the  berries. 

The  symptoms  are  vomiting,  convulsions,  dilated  pupils, 
and  coma,  wliich  usually  ends  in  death. 

Stimulants  are  principally  to  be  relied  on  in  the  treat- 
ment. 

CAMPHOK 

Is  a  concrete  substance  obtained  from  the  Camphora 
officinalis,  an  evergreen  tree  of  Cliina  and  Asia.  It  rarely 
produces  death.  Taylor  relates  the  case  of  a  man  who,  in 
twenty  minutes  after  taking  the  drug,  was  seized  with 
vertigo,  dimness  of  vision,  and  convulsions.  The  pulse 
became  rapid  and  weak,  the  extremities  cold.  The  stomach 
was  emptied  by  a  stomach-pump.     He  suffered  for  a  week 


NARCOTIC  POISONS.  225 

subsequently  with  exhaustion,  and  from  suppression  of 
urine. 

In  some  cases  there  are  pain  in  the  back,  and  rapid  in- 
sensibility. 

The  breath  of  a  person  poisoned  by  camphor  smells 
strongly  of  the  drug,  and  thus  the  diagnosis  is  readily 
made. 

Treatment. — Free  emesis  should  be  procured  without 
delay.     Stimulants  are  always  necessary. 

ALCOHOL. 

Large  quantities  of  alcohol,  in  the  shape  of  whiskey, 
brandy,  etc.,  have  produced  sudden  death  in  young  persons 
unaccustomed  to  the  poison.  Convulsions  and  coma  are 
not  unfrequent  accompaniments  of  excessive  indulgence  in 
ardent  spirits  {Taylor).  (For  characteristic  appearances 
and  treatment,  see  Convulsions.)  Chronic  poisoning  by 
alcohol  is  recognized  by  the  bloated  countenance,  blood- 
shot eyes,  general  tremulousness,  and  delirium  tremens. 

The  treatment  for  this  condition  consists  in  total  absti- 
nence from  liquor,  and  the  administration  of  bromide  of 
potassium. 

CHLOEOFOEM. 

This  substance  is  one  of  the  most  effective  anaesthetics 

known.     Its  formula  is  C2HCI3.     It  is  technically  known  as 

the  terchloride  of  formyl.     It  is  prepared  by  the  action  of 

chlorinated  lime  on  wood-spirit.    "When  inhaled,  it  first  acts 

as  a  stimulant,  causing  great  excitability  and  intoxication, 

then  mental  hallucination  and  delirium,  and  finally  perfect 

insensibility  and  coma. 
15 


226  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

In  the  third  stage,  when  the  inhalations  are  carried 
beyond  a  certain  point,  the  pulse  becomes  very  small  and  in- 
termittent, respiration  slow,  irregular,  and  difficult ;  face 
congested,  and  lips  livid. 

If  organic  disease  of  the  heart  exist,  very  small  quanti- 
ties may  produce  death.  Sometimes  respiration  is  suddenly 
suspended,  and  death  ensues  rapidly.  In  one  instance  I 
have  seen  it  produce  convulsions.  Chloroform  kills  by  as- 
phyxia, syncope,  or  coma.  After  death  the  lungs  are  con- 
gested and  filled  with  dark  blood. 

Treatment. — Artificial  respiration  is  the  main  reliance 
in  the  treatment  of  chloroform-poisoning.  Marshall  Hall's 
or  Sylvester's  method  will  answer  {see  chapter  on  Drowning). 
Inhalation  of  pure  oxygen  is  always  beneficial.  In  some 
cases  it  may  be  forced  into  the  lungs  through  an  opening  in 
the  trachea.  Slapping  the  patient,  and  pouring  cold  water 
on  the  surface,  are  also  recommended.  Galvanism  has  been 
successful  in  restoring  life  in  one  or  two  cases.  Some  rely 
solely  on  electrical  stimulus  in  the  treatment. 

ETHER  (C4H5O) 

Is  manufactured  by  the  action  of  sulphuric  acid  upon 
alcohol.  The  acid  merely  removes  the  water  from  the 
alcohol,  to  form  the  ether.  The  action  of  the  vapor  of 
ether  is  similar  to  that  of  chloroform.  Its  effects  are,  how- 
ever, manifested  more  slowly ;  the  resulting  ancesthesia  con- 
tinues longer,  and  larger  quantities  of  the  drug  are  required 
to  produce  the  same  degree  of  insensibility. 

The  symptoms  accompanying  poisoning  by  ether  are 
the  same  as  are  witnessed  in  chloroform-poisoning,  and  a 
similar  treatment  must  be  pursued. 


NARCOTIC  POISONS.  227 

CHLOEAL. 

This  drug  has  lately  come  into  general  use  as  an  ano- 
dyne and  hypnotic.  It  is  made  by  the  action  of  chlorine 
gas  on  alcohol.  It  is  used  in  the  form  of  a  hydrate.  When 
taken  into  the  system  it  is  changed  into  chloroform  by  the 
action  of  the  soda  of  the  blood. 

Its  poisonous  influences  are  manifested  by  laborious  and 
irregular  breathing,  congestion  of  the  face,  rapid  and  feeble 
pulse,  numbness,  and  insensibility.  In  some  cases  there  is 
considerable  disturbance  of  the  mental  faculties. 

After  death  the  same  lesions  are  found  as  exist  in  poison- 
ing from  chloroform. 

Treatment. — Some  recommend  hypodermic  injections 
of  strychnia  as  an  antidote.  Artificial  respiration,  inhala- 
tions of  oxygen,  and  stimulation  are  mainly  to  be  relied  on. 
Electricity  is  also  beneficial. 

HYDEOCYANIC  ACID. 

The  common  name  of  this  drug  is  prussic  acid.  It  is 
obtained  from  bitter-almonds,  peach-kernels,  cherry-laurel, 
prunus  Yirginiana,  and  bitter  cassava.  It  is  formed  in.  bit- 
ter-almonds by  the  reaction  of  a  peculiar  principle  called 
amygdaline,  and  water.  The  change  is  excited  by  the  pres- 
ence of  a  nitrogenized  body  called  emulsine. 

The  essential  oil  of  bitter- almonds  is  employed  as  a 
flavoring  extract.  Almond-water  and  laurel-water  are  used 
for  a  similar  purpose. 

Prussic  acid  is  manufactured  by  the  action  of  sulphuric 
acid  upon  ferrocyanide  of  potassium,  or  by  the  action  of 
muriatic  acid  upon  the  cyanide  of  silver. 


228  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

The  acid  obtained  hj  tliis  process  is  in  a  dilute  form, 
and  contains  about  two  per  cent,  of  tlie  anhydrous  vari- 
ety. It  is  colorless,  and  possesses  a  peculiar  odor  resembling 
peach-kernels  or  almonds. 

It  is  one  of  the  most  deadly  substances  known,  killing 
more  rapidly,  and  aflfording  less  oj)portunity  for  recovery, 
than  any  other  poison.  Inhalation  of  its  vapor  in  a  con- 
centrated form  has  in  some  instances  produced  almost  in- 
stant death.  Scheele,  -while  pursuing  his  chemical  investi- 
gations with  this  drug,  died  instantly  by  inhaling  his  own 
preparation  of  it.  A  single  drop  of  the  anhydrous  acid 
placed  on  the  tongue  will  kill  instantly.  A  drachm  of  the 
dilute  acid  will  destroy  life  in  a  few  seconds,  unless  im- 
mediate efforts  at  restoration  are  made.  The  poison  acts 
as  rapidly  if  placed  in  a  wound.  In  some  instances  life  is 
prolonged  for  three  or  four  minutes  when  poisonous  quan- 
tities are  swallowed.  In  one  or  two  rare  cases  a  fatal 
termination  did  not  occur  for  an  hour  after  tlic  adminis- 
tration of  the  poison. 

Tests. — Taylor  mentions  three  principal  chemical  tests  : 
1.  Kitrate  of  silver,  which  gives  a  white  precipitate  of  the 
cyanide  of  silver;  2.  On  the  addition  of  potash,  and  a  solu- 
tion of  the  sulphate  of  iron,  there  is  a  brownish-green  pre- 
cipitate, which,  changes  into  blue,  upon  the  addition  of 
diluted  muriatic  acid.  The  blue  substance  thrown  down  is 
ferrocyanide  of  iron,  or  Prussian  blue ;  3.  Bihydrosulphate 
of  ammonia,  when  added  to  the  suspected  solution  and 
warmed,  makes  the  mixture  colorless,  and  after  evaporation 
leaves  sulphocyanate  of  ammonia,  whicli  is  recognized  by 
the  "  blood-red  "  color  produced  by  adding  a  solution  of  the 
colorless  persulphate  of  iron. 


NARCOTIC  POISONS.  229 

When  large  closes  of  the  drug  are  taken,  the  patient  falls 
unconscious  to  the  ground,  the  face  becomes  congested, 
respiratory  movements  labored,  and  diminished  in  length 
and  frequency ;  pupils  dilated,  eyes  glassy  and  prominent, 
pulse  imperceptible,  skin  clammy  and  cold.  Foam  collects 
on  the  lips,  the  jaw  drops,  and  death  supervenes.  If  small 
quantities  are  taken,  and  the  symptoms  develop  more 
slowly,  there  are  difficult  and  convulsive  efforts  at  breath- 
ing, the  movements  occurring  at  long  intervals,  vertigo, 
oppression  over  the  precordial  region,  muscular  weakness, 
and  paralysis  {Bacher).  The  eyes  are  prominent,  and  there 
are  sometimes  convulsive  movements,  and  loud  cries  from 
the  patient. 

HhQ post-mortem  appearances  vary.  The  peculiar  almond 
odor  is  nearly  always  exhaled  from  the  body.  The  lungs, 
brain,  liver,  and  kidneys,  are  filled  with  dark  fluid.  The 
eyes  are  remarkably  bright  and  staring.  In  some  instances 
the  muscles  will  not  respond  to  galvanic  stimulus. 

The  symptoms  appertaining  to  poisoning  by  almond-oil, 
cherry-laurel,  or  cyanide  of  potassium,  are  developed  more 
slowly  than  the  preceding.  Their  main  features  and  treat- 
ment are  alike. 

Treatment. — Chlorinated  lime  in  solution,  chlorine- 
water,  or  ammonia  in  vapor  largely  diluted,  are  good  anti- 
dotes. Another  method  employed  is  to  change  the  prussic 
acid  in  the  stomach  into  Prussian  blue.  According  to  the 
"  United  States  Dispensatory,"  this  is  done  in  the  following 
manner :  Ten  grains  of  sulphate  of  protoxide  of  iron  and  one 
drachm  of  Tr.  ferri  chlor.  are  added  to  an  ounce  of  water, 
and  twenty  grains  of  carbonate  of  potassium  to  one  ounce  of 
water  in  another  vessel.     The  latter  solution  is  swallowed 


230      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

first,  and  immediately  followed  by  the  preparation  of  iron. 
Cold  water  poured  from  a  height  upon  the  face,  chest,  and 
abdomen,  and  artificial  respiration,  are  also  recommended 
as  efficacious  remedies. 

WOOEAKA. 

The  source  of  this  poison  has  been  the  subject  of  con- 
siderable controversy.  Schomberg  thought  it  was  a  product 
of  a  plant  called  Strychnia  ioxifera.  JSTo thing  analogous  to 
the  action  of  strychnia  has,  however,  been  found  in  it,  and 
there  is  no  definite  account  of  its  origin.  Prof.  "W.  A. 
Hammond,  from  numerous  experiments  made  with  the 
drug,  believed  its  action  to  be  exerted  mainly  on  the  heart, 
paralyzing  that  organ.  It  was  also  thought  to  produce  a 
paralysis  of  the  sympathetic  and  motor  nerves.  Woorara  is 
employed  by  the  natives  of  South  America  to  poison  the 
heads  of  arrows.  It  exerts  its  peculiar  efi*ects  by  being 
introduced  through  wounds.  "When  taten  into  the  stomach 
it  is  often  inert.  The  symptoms  attending  a  wound  poi- 
soned with  woorara  are  sudden  stupor  and  insensibility, 
frothing  at  the  mouth,  rapid  cessations  of  the  respiratory 
movements  and  pulsations  of  the  heart.  Some  writers  say 
that  the  heart  continues  its  action  some  moments  after  res- 
piration has  ceased. 

Treatment. — ^When  the  poison  enters  a  wound,  the  part 
should  be  sucked  and  excised,  and  a  ligature  placed  around 
the  limb  between  the  wound  and  the  heart.  Brainard  and 
Green  discovered  that  a  solution  of  iodine  and  iodide  of 
potassium  neutralized  the  poison,  and  recommend  its  ap- 
plication to  the  wound,  and  also  its  internal  administration. 
Chlorine  and  bromine  are  also  said  to  have  a  similar  efiect. 


NARCOTIC  POISONS.  231 

Artificial  respiration  has  been  tried  on  criminals  poi- 
soned bj  woorara,  and  has  been  followed  by  good  results. 

CALABAR  BEAN. 

Calabar  bean  is  a  seed  of  the  Plysostigma  venonosum,  a 
climbing  plant  of  Calabar.  It  is  used  by  the  negroes  of 
Africa  as  an  ordeal-bean — the  guilt  or  innocence  of  the 
individual  being  determined  by  its  action  on  the  system. 
If  a  dose  is  taken  without  subsequent  unfavorable  symp- 
toms, the  person  is  declared  innocent.  If  the  contrary,  a 
verdict  of  guilty  is  announced. 

Its  action  on  animals  is  said  to  resemble  that  of  woorara. 
It  paralyzes  the  heart  and  motor  nerves. 

Poisonous  doses  in  man  produce  vertigo,  dimness  of 
vision,  great  weakness,  small,  intermittent  pulse,  contrac- 
tion of  the  pupil,  insensibility,  and  death. 

Treatment. — The  stomach  should  be  evacuated,  stim- 
ulants administered  internally,  and  the  surface  briskly 
rubbed.  Hypodermic  injections  of  strychnia  might  be 
tried.  Strychnia  exerts  an  entirely  opposite  effect  on  the 
spinal  cord.     Electricity  is  also  worthy  of  a  trial. 

UPAS-TREE. 

This  tree  grows  in  various  parts  of  the  East  Indies.  A 
resinous  exudation,  obtained  by  incisions  in  the  bark,  acts  on 
the  system  as  a  virulent  poison.  Like  woorara,  it  is  prin- 
cipally employed  by  the  natives  to  poison  arrow-heads. 
The  vapor  of  the  tree  at  certain  seasons  of  the  year  is  said 
to  cause  eruptions  on  the  skin. 

"When  applied  to  a  wound,  or  taken  internally,  it  causes 
great  muscular  weakness,  syncope,  nausea,  and  vomiting. 


232      EMERGENCIES,  AND  nOW  TO  TREAT  THEM. 

relaxed   spliincters,  tliready,  irregular  pulse,  and   convul- 
sions. 

Treatment. — The  remedies   employed  in  poisoning  by 
tobacco,  or  aconite,  are  applicable  to  tliese  cases. 


SPIXANTS. 

NTJX-voMiCA  {Strychnia). 

Strychnia  is  derived  from  the  seed  of  the  Strychnos  nux- 
vomica  and  the  Strych7ios  ignatia,  large  trees  of  the  East 
Indies  and  other  Eastern  countries.  The  seeds  are  embedded 
in  the  pulp  of  the  fruit.  They  are  circular  in  shape,  three- 
quarters  of  an  inch  wide,  about  the  thickness  of  a  cent-piece, 
and  are  covered  with  delicate,  yellowish-gray  hairs.  Strych- 
nia exists  in  the  seed,  together  with  brucia  and  igasuria. 
The  nux-vomica  and  its  alkaloids  possess  the  same  action 
on  the  system,  the  only  difference  being  in  the  rapidity 
with  which  their  characteristic  symptoms  are  manifested. 
Strychnia,  which  is  the  most  powerful  ingredient  of  the 
nut,  or  seed,  is  found  in  the  shops  in  the  form  of  a  fine, 
white,  crystalline  powder,  with  an  extremely  bitter  taste. 
Its  bitterness  is  so  marked  that  one  part  will  give  a  taste  to 
six  hundred  thousand  parts  of  water  {U.  S.  Disp.).  Yery 
small  quantities  suffice  to  produce  a  fatal  result ;  one-tenth 
of  a  grain  has  killed  a  dog.  There  are  instances  recorded 
where  half  a  grain  has  proved  fatal  to  human  beings. 
In  exceptional  cases  recovery  has  taken  place  after  the 
administration  of  four  or  five  grains. 

Strychnia  acts  specially  on  the  spinal  cord,  but  there  is 
no  good  reason  for  supposing  that  it  does  not  in  a  measure 


SPINANTS.  233 

affect  tlie  brain.  I  have  seen  a  certain  amount  of  vertigo 
and  rapid  utterance  follow  its  use. 

There  are  several  tests  of  the  presence  of  this  drug.  In 
Mararchard's  process,  five  or  six  drops  of  concentrated 
sulphuric  acid,  arid  one  hundredth  part  of  nitric  acid,  are 
mixed  with  the  suspected  solution  ;  a  little  protoxide  of  lead 
is  then  added,  and,  if  the  strychnia  is  present,  a  blue  color 
appears,  which  changes  to  violet,  red,  and  finally  to  yellow. 

If  the  strychnia  is  in  solution  in  sulphuric  acid,  the  addi- 
tion of  a  bichromate-of-potash  solution  will  give  a  violet 
hue.  This  test  will  detect  the  one  million  five  hundred 
thousandth  part  of  a  grain  {U.  S.  Disp.). 

Poisonous  doses  of  strychnia  first  produce  an  inability 
to  remain  in  one  position,  and  a  tendency  to  perform  every 
motion  with  great  rapidity.  The  muscles  seem  to  be  be- 
yond control  of  the  will,  and  twitch  unceasingly.  There 
are  some  constriction  in  the  throat,  difficult  respiration, 
and  feeling  of  oppression  about  the  chest.  Violent  mus- 
cular spasms  then  appear;  they  are  tonic  or  continuous 
in  character,  resembling  those  occurring  in  tetanus.  The 
muscles  of  the  back  are  often  affected  more  than  those  of 
the  extremities,  and  as  a  result  the  body  is  bent  like  a  bow, 
and  rests  on  the  head  and  heels  (opisthotonos).  Dm*ing 
the  paroxysm  the  jaws  are  tightly  fixed,  the  face  dark  and 
congested  from  the  accumulation  of  blood  in  the  veins. 
Contraction  of  the  muscles  prevents  expansion,  of  the  chest, 
and  obstructs  the  blood  going  to  the  thorax,  and  hence  the 
congestion.  Intermissions  in  the  severity  of  the  paroxysms 
may  occur;  they  last  but  a  moment.  Death  takes  place 
from  the  spasm  of  the  muscles  of  respiration  inducing 
asphyxia. 


234      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

On  jpost-mortem  examination  there  are  usually  a  dark 
color  of  tlie  ftice,  congestion  of  tlie  brain,  cord,  and  tlieir 
membranes,  and  congestion  of  tlie  lungs.  The  right  side 
of  the  heart  contains  a  large  quantity  of  dark  blood,  and 
the  left  side  is  empty. 

Treatment. — Chloroform  taken  in  a  liquid  state  or  by 
inhalations  should  in  all  cases  be  tried.  A  relaxation  of  the 
spasms  "will  at  least  prevent  or  retard  the  occurrence  of 
asphyxia.  Infusion  of  tobacco  is  recommended  by  some.  It 
may  be  advantageously  combined  with  chlorofonn;  that 
is,  the  tobacco-infusion  can  be  swallowed,  or  given  by 
enema,  while  anaesthesia  is  procured  by  inhalation  of  chlo- 
roform. Aconite  has  been  used  in  some  cases  wuth  benefit. 
Thoral  employs  preparations  of  antimony  as  an  antidote;  it 
is  given  in  emetic  doses.  Boudecker  experimented  upon 
dogs  with  chlorine-water  and  tartar-emetic,  giving  them 
alternately.  He  claims  to  have  saved  the  animals  from  the 
poisonous  effects  of  strychnia  by  this  treatment. 

It  will  be  well  in  most  instances  to  commence  treatment 
by  an  emetic,  in  order  to  get  rid  of  the  poison  remaining 
in  the  stomach.  The  infusion  of  tobacco,  or  sulphate  of 
zinc,  will  answer  this  purpose.  If  the  patient  cannot  swal- 
low the  medicine,  it  can  be  given  through  the  rectum. 


CHAPTER  XXI. 

IRRITANT    POISONS. 

Cantharides . — C roton-oil. — Veratria.  — IIol  1  ebore ,  etc. 

A  PECULIAR  Spanish  fly,  called  the  Cantharis  vesicato- 
ria,  has  long  been  employed  in  medicine  as  a  vesicant  and 
as  a  stimulant  to  the  genito-urinary  apparatus.  There  are 
several  other  varieties  of  cantharides  found  in  the  southern 
parts  of  this  country,  which  possess  properties  analogous 
to  the  Spanish  fly ;  they  are,  however,  rarely  employed  for 
medicinal  purposes. 

Large  doses  of  cantharides  produce  tenesmus  at  the  neck 
of  the  bladder,  inability  to  pass  water,  intense  pain  and 
scalding  with  the  few  drops  of  urine  which  are  squeezed 
through  {strangury),  great  pain  throughout  the  alimentary 
canal,  and  thirst,  with  profuse  vomiting  and  purging.  The 
vomited  matters  and  the  stools  contain  blood.  The  extremi- 
ties are  cold.  There  are  great  prostration,  a  rapid  pulse, 
sighing  respiration,  and  a  fetid  odor  to  the  breath. 

A  j>ost-mortem  examination  shows  signs  of  inflammation 
in  the  stomach  and  intestinal  canal. 

Treatment. — ^When  the  stomach  and  bowels  have  been 
emptied  of  their  contents  by  emetics,  cathartics,  or  the 
natural  efforts  of  the  patient,  ten  to  thirty  drops  of  liquor 
potassa  largely  diluted  may  be  given  every  hour  {Mulack\ 


236      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

ia  conjunction  -with  liot  applications  to  the  hypogastric 
regions.  Small  pieces  of  ice  may  be  swallowed  with  benefit. 
Thale  recommends  animal  charcoal  as  an  antidote;  a  tea- 
spoonfiil  of  this  substance  mixed  witli  a  little  water  may  be 
given  at  a  dose. 

OIL    OF    SAVIN. 

The  tops  and  leaves  of  Junijjcrus  sabuia,  or  red  cedar, 
furnish  a  volatile  oil  which  possesses  marked  irritant  proper- 
ties. The  oil  is  employed  in  medicine  as  a  stimulant  to  the 
secretions,  and  as  an  emmenagogue.  Its  action  on  the  uterus 
is  denied  by  some  authorities.  It  is  commonly  administered 
by  quacks  and  others  to  produce  abortion.  These  cases  not 
infrequently  terminate  fatally. 

A  decoction  and  infusion  of  the  tops  and  leaves  are  also 
used  for  a  similar  purpose. 

An  overdose  produces  strangury,  sharp  pains  in  the 
bowels,  hot  skin,  rapid  pulse,  yiolent  vomiting,  and  some- 
times pm-ging.  The  vomited  matters  are  often  of  a  green 
color.  Great  prostration  comes  on  rapidly,  and  usually  ends 
in  death. 

The  jpost-mortera  appearances  are  the  same  as  those  ob- 
served in  poisoning  by  cantharides. 

Treatment. — ^Warm  fomentations  over  the  epigastrium 
and  hypodermic  injections  of  morphia  may  be  tried  with 
benefit.  The  patient  should  be  fed  through  the  rectum  if 
possible.  Nothing  but  ice  should  be  allowed  in  the  stomach 
until  the  subsidence  of  the  inflammation. 

CEOTON  on.. 
Is    a    product    of   the    seeds    obtained    trom    the  Croton 
tiglium,  a  small  tree  of  Hindostan.     It  is  a  drastic  hydra- 


IRRITANT  POISONS.  237 

gogue  cathartic,  acting  efficiently  in  from  a  lialf  to  one  hour 
after  its  administration.  Applied  externally  it  produces  a 
pustular  eruption.  In  large  doses  it  excites  inflammation 
of  the  oesophagus,  stomach,  and  intestines,  and  gives  rise  to 
vomiting,  purging,  and  rapid  prostration. 

Treatment. — Empty  the  stomach  thoroughly,  and  treat 
the  resulting  inflammation  in  the  usual  manner.  Stimulants 
diluted  vs^ith  iced  milk  should  also  be  used,  to  sustain  the 
strength  of  the  patient. 

COLCHICUM. 

The  tinctures  and  decoctions  of  this  drug  are  not  infre- 
quently taken  in  poisonous  doses  by  careless  persons.  Three 
drachms  of  the  wine  of  the  seeds  have  caused  death.  The 
poisonous  effects  are  manifested  by  violent  vomiting  and 
purging,  great  pain,  and  collapse. 

The  treatment  is  the  same  as  for  the  preceding  varieties. 

TEEATKIA. 

This  alkaloid  is  obtained  from  the  seeds  of  Veratrum 
sdbadilla  and  other  plants.  It  is  found  in  the  shops,  in  the 
form  of  a  grayish-white  powder.  The  taste  is  bitter.  It 
gives  a  red  color  with  sulphuric  acid,  and  a  yellow  color 
with  nitric  acid. 

Yeratria  is  a  powerful  poison  in  doses  of  four  or  five 
grains.     Half  a  grain  has  proved  fatal  to  a  child. 

The  symptoms  of  poisoning  are  vomiting  and  purging, 
pain  in  the  epigastrium,  rapid  respiration,  small,  quick  pulse, 
and  spasmodic  movements  of  the  muscles,  resembling  those 
which  occur  in  tetanus. 


238  EMERGENCIES,  -\:S'D   HOW  TO   TREAT  THEM. 

Tlie  antidotes  are  vinegar,  vegetable  astringents,  Lngol's 
solution,  and  stimulants. 

Black  and  -vrliite  liellebore,  all  the  drastic  cathartics, 
turpentine,  etc.,  are  irritant  poisons  in  large  doses.  They 
present  similar  symptoms  to  those  irritants  previously  men- 
Honed,  and  require  the  same  treatment. 


'       CHAPTER  XXII. 

METALLIC     POISONS. 
AKSENIC. 

EvEKY  prej^Aration  of  arsenic  acts  as  an  irritant  poison. 
Among  tlie  most  common  varieties  are  arsenious  acid, 
arsenite  of  copper  (Scheele's  green) ;  yellow  sulphuret  of 
arsenic  (orpiment) ;  and  red  arsenic,  or  realgar.  Arsenious 
acid  and  Scheele's  green  are  most  frequently  employed  for 
purposes  of  murdei*  or  suicide. 

Metallic  arsenic  is  made  by  heating  an  oxide  of  arsenic 
with  charcoal. 

Arsenious  acid  (AsOs)  is  obtained  during  the  sublima- 
tion of  the  arseniuret  of  cobalt  and  iron.  It  usually  exists 
in  the  shops  as  a  fine  white  powder.  If  the  sublimation 
has  been  slow,  it  will  take  the  form  of  brilliant  octahedral 
crystals  {Taylor).  It  combines  with  many  of  the  alkalies, 
as  soda,  ammonia,  or  potash,  to  form  salts.  The  well-known 
Fowler's  solution  is  a  liquid  preparation  of  the  arsenite  of 
potash. 

Scheele's  green  is  applied  to  a  variety  of  purposes.  It 
is  the  principal  ingredient  in  the  coloring  matter  of  green 
wall-paper,  artificial  flowers,  candy  and  paper  boxes,  etc. 
Nearly  all  the  bright-green  colors  of  household  furniture, 
paper,  and  "  knick-knacks,"  are  made  by  this  poison.     This 


24,0  EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

indiscriminate  and  unguarded  use  lias  resulted  in  serious 
impairment  of  healtli  and  loss  of  life.  Inhalations  of  the 
microscopical  particles,  "which  arise  from  the  green  surface 
of  room-paper,  may  induce  all  the  poisonous  effects  of 
arsenic.     Cases  are  not  rare  where  this  has  occurred. 

Eealgar  and  orpinient  are  much  used  also  as  coloring 
matters,  but  less  extensively  than  arsenite  of  copper. 

Arsenious  acid  (AsOs)  is  a  very  powerful  poison,  hut 
loss  of  life  from  its  administration  is  exceedingly  rare. 

Arsenious  acid  kills  in  from  three  to  forty-eight  hours. 
The  length  of  time  varies  with  the  dose,  the  condition  of  the 
stomach,  and  age  of  the  patient.  Christoson  gives  the 
smallest  fatal  doses  of  the  preparation  as  thirty  grains  of 
the  powder,  and  four  grains  in  solution.  Taylor  relates  a 
case  where  two  or  three  grains  in  powder  proved  fatal. 

Tests. — Ammonia  nitrate  of  silver,  added  to  a  solution 
of  arsenious  acid,  throws  down  a  yellow  precipitate,  which 
is  the  arsenite  of  silver.  Ammonia  sulphate  of  copper 
gives  a  green  precipitate  of  arsenite  of  copper. 

Marsh's  test  is  the  most  reliable.  It  consists  in  adding 
sulphuric  acid  and  zinc  to  the  arsenical  solution,  and  form- 
ing arsenurettcd  hydrogen.  The  gas,  as  it  passes  out 
through  the  tube,  is  set  on  fire.  The  presence  of  arsenic  is 
known  by  the  garlicky  odor,  and  by  the  blue  color  of  the 
liame.  In  addition,  if  a  porcelain  slate  is  held  near  the 
flame,  a  black  ring  of  metallic  arsenic  is  deposited,  and  on 
the  outside  of  this  ring  a  whitish  film  of  ai-senious  acid 
appears.  To  determine  whether  the  deposit  is  arsenic  or 
antimony,  the  plate  is  subjected  to  a  high  temperature,  and, 
if  arsenic  is  present,  the  substance  is  immediately  vola- 
tilized ;  if  antimony,  it  will  remain. 


METALLIC  POISOXS.  241 

Rienscli's  test  consists  in  boiling  slips  of  copper  in  an 
acidulated  solution  of  the  suspected  liquid.  The  mixture 
is  heated  to  the  boiling-point,  and  a  slip  of  copper  dipped 
in  it  for  five  or  ten  minutes.  If  arsenic  is  present,  it  will 
be  deposited  on  the  copper,  and  will  appear  of  a  dark-gray 
color.  If  the  material  thus  obtained  is  heated  in  a  tube, 
the  metallic  arsenic  is  changed  into  arsenious  acid,  which 
is  recognized  by  its  peculiar  bright  octahedral  crystals. 

Scheele's  green  and  other  preparations  of  arsenic  are 
distinguished  by  the  same  reagents.  In  all  cases  the 
arsenic  may  be  reduced  to  arsenious  acid  by  heat,  while 
the  latter  can  be  recognized  by  its  crystals. 

Small  and  repeated  doses  of  arsenic  may  produce  slow 
poisoning.  The  constitutional  effects  of  the  drug  adminis- 
tered in  this  manner  are  recognized  by  a  pale,  waxy  look 
on  the  face,  oedema  of  the  eyelids  and  sometimes  of  the 
extremities,  loss  of  appetite,  pain  in  the  stomach,  nausea,  or 
vomiting,  eruptions  on  the  cutaneous  surface,  feeble  pulse, 
and  great  weakness.  In  some  cases  the  urine  is  loaded 
with  albumen.  If  the  drug  be  continued,  death  soon 
ensues. 

When  large  doses  of  arsenic  are  taken,  there  is  pain 
in  the  epigastric  region,  which  rapidly  increases,  and  is 
aggravated  by  pressure.  There  are  nausea  and  vomiting. 
At  first,  the  vomited  matter  consists  of  the  contents  of  the 
stomach,  vrith  particles  of  arsenic  intermixed.  Subse- 
quently, they  contain  blood  and  thick  mucus.  Purging 
usually  follows  the  vomiting,  in  about  half  an  hour  after  the 
prominent  symptoms  are  developed.  There  are  sometimes 
soreness  and  constriction  about  the  throat.    The  respiration 

becomes  entirely  thoracic,  and  the  movements  are  short  and 
16 


242      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

rapid.  The  pulse  is  quick,  small,  and  intermittent.  Death 
may  be  preceded  by  coma  and  convulsions. 

In  poisoning  from  corrosive  sublimate,  the  symptoms  are 
developed  more  rapidly  than  in  arsenical  poisoning.  In  the 
former  there  is  greater  pain  in  the  throat,  and  in  the  course 
of  the  CEsophagus,  and  the  tongue,  fauces,  and  throat,  present 
a  white  appearance.  These  signs  suffice  to  distinguish  the 
two  forms. 

After  death  from  arsenic,  the  mucous  membrane  of  the 
stomach  is  congested,  thickened,  and  softened.  There  is 
more  or  less  redness  over  the  wbole  organ,  but  marked  in 
the  most  dependent  portions.  Collections  of  mucus,  mixed 
with  blood  and  arsenic,  are  found  in  isolated  patches  in 
diiFerent  parts  of  the  stomach.  Arsenic  does  not  act  as  a 
corrosive  poison ;  it  never  produces  ulceration  of  the  mucoua 
membrane. 

Treatment. — The  antidote  for  arsenious  acid  is  the 
hydrated  sesquioxide  of  iron.  It  is  prepared  by  adding  aqua 
ammonia,  soda,  or  potash,  to  a  solution  of  tbe  persulphate 
of  iron.  When  tbe  alkali  is  added,  a  reddish-brown  powder 
forms,  which  is  administered  ad  libitum  both  to  adults  and 
children.  The  iron  combines  with  the  arsenic,  and  the 
insoluble  subarseniate  of  the  protoxide  of  iron  is  thrown 
down  (  U.  S.  Disp.).  Preceding  the  administration  of  the 
antidote,  the  stomach  should  be  thoroughly  emptied  witk 
the  stomach-pump,  or  by  emetics  of  sulphate  of  zinc^ 
mustard,  or  ipecac,  assisted  by  copious  draughts  of  warm 
water. 

Preparations  of  magnesia  are  recommended  as  antidotes^ 
Lime-water,  mixed  with  oil,  and  mucilaginous  drinks,  maj 
be  given  also. 


METALLIC  POISONS.  243 

The  antidote  for  the  salts  of  arsenic  is  the  subacetate 
of  the  protoxide  of  iron  {Duflos). 

Fewtrell  recommends  the  administration  of  a  mixture 
of  chalk  and  castor-oil,  made  into  a  thick  paste. 

When  the  stomach  is  cleansed  and  the  antidotes  given, 
the  treatment  should  be  directed  to  allay  pain,  and  relieve 
the  gastric  inflammation,  by  hypodermic  injections  of  mor- 
phia, internal  administration  of  ice,  and  blisters  to  the 
epigastrium. 

coKKosivE  SUBLIMATE  {JBichloride  of  Mercury). 

Mercury  in  the  metallic  state  is  inert.  When  taken 
internally  it  passes  through  the  bowels  with  scarcely  any 
change.  An  extremely  small  quantity  may  be  oxidized,  but 
not  sufficient  to  affect  the  system.  Many  of  the  combina- 
tions of  mercury  act  as  corrosive  and  irritant  poisons. 
The  most  deadly  is  corrosive  sublimate.  This  substance, 
according  to  American  authorities,  consists  of  two  atoms 
of  chlorine  united  to  one  of  mercury.  The  British  Phar- 
macopoeia, however,  makes  it  a  protochloride,  consisting 
of  equal  parts  of  chlorine  and  mercury.  The  bichloride 
is  made  by  subliming  sulphuric  acid  and  mercury  together, 
and  then  adding  chloride  of  sodium.  It  occurs  in  small 
white  or  transparent  crystals,  and  is  exceedingly  soluble. 

Tests. — Iodide  of  potassium  gives  a  scarlet-colored  pre- 
cipitate of  the  biniodide  of  mercury.  Ammonia  throws 
down  a  white  precipitate  of  ammoniated  mercury.  Lime- 
water  gives  a  yellow  precipitate  of  the  hydrated  deut oxide 
of  mercury.  A  black  precipitate  is  formed  by  sulphuretted 
hydrogen.  If  a  piece  of  zinc  and  gold  wire  be  dipped  in 
the  suspected   solution,  which  has  been  slightly  acidulat- 


244      EMERGENCIES,  AND  HOW  TO  TREAT  TUEM. 

ed,  a.grajisli  deposit  of  mercury  will  take  place  on  the 
metal. 

In  small  doses,  continued,  it  produces  ptvalism  and 
other  characteristic  effects  of  mercurial  preparations.  The 
patient's  gums  become  red,  tender,  swollen  and  ulcerated  ; 
saliva  is  poured  out  in  excessive  quantities.  There  is  a 
strong  metallic  taste  in  the  mouth,  and  the  breath  has  a 
fetid  odor.  A  blue  line,  in  some  cases,  may  be  noticed 
around  the  edge  of  the  gums.  The  teeth  loosen,  and  the 
throat  becomes  sore  and  inflamed.  The  blood  loses  its 
plasticity,  and  the  red  globules  are  diminished.  If  allowed 
to  proceed  without  treatment,  these  symptoms  are  intensi- 
fied ;  necrosis  of  bone  and  ulceration  of  the  integument  are 
added,  and  the  patient  dies  from  exhaustion. 

Corrosive  sublimate  has  been  known  to  destroy  life  in 
doses  of  three  grains  {Taylor').  Usually  it  takes  from  ten 
grains  to  a  drachm.  In  a  few  cases  much  larger  doses  have 
been  recovered  from. 

The  symptoms  produced  by  poisonous  doses  are  those 
common  to  many  corrosive  poisons.  A  burning  pain  is 
felt  along  the  oesophagus  and  in  tlie  stomach,  a  few  mo- 
ments after  the  drug  is  swallowed.  This  is  followed  by 
vomiting  and  purging  of  slimy  mucus,  marked  with  blood. 
Portions  of  mucous  membrane  have  been  thrown  up  with 
the  evacuations.  The  mouth  and  throat  have  a  white 
appearance,  and  a  strong  metallic  taste  is  experienced. 
There  are  thirst,  difficulty  in  swallowing,  a  feeling  of  oppres- 
sion on  the  chest,  and  difficulty  in  breathing.  The  pain  in 
the  stomach  increases  in  intensity,  the  pulse  becomes  small 
and  thready,  extremities  cold ;  great  prostration  comes  on, 
which  is  soon  followed  by  death 


METALLIC  POISONS.  245 

The  mucous  membrane  lining  the  oesophagus  and  stom- 
ach present  after  death  a  slate-gray  appearance.  The  mem- 
brane is  softened,  and  may  be  ulcerated.  Extravasations  of 
blood  are  found  beneath  it,  and  occasionally  on  the  surface. 
If  a  piece  of  the  rnembrane  is  taken  up  with  a  forceps,  it  is 
easily  separated.  There  are  also  redness  and  tumefaction, 
particularly  marked  in  the  great  cul-de-sac  of  the  stomach. 

Treatment.  —  When  profase  salivation  arises  from 
medicinal  doses  of  corrosive  sublimate,  or  other  prepara- 
tions of  mercury,  iodide  of  potassium  is  given  as  an  anti- 
dote in  conjunction  with  chlorate  of  potash.  A  solution  of 
the  latter  makes  an  efficient  wash  for  the  ulcerated  mouth. 
Carbonic  acid,  in  the  proportion  of  one  drachm  to  four 
ounces  of  water,  is  an  excellent  application  for  the  same 
part. 

"When  poisonous  doses  of  the  bichloride  have  been  taken, 
the  stomach  should  be  emptied  rapidly  and  completely 
with  emetics  or  the  stomach-pump.  The  common  antidote, 
aWumen,  may  then  be  administered,  in  the  form  of  white 
of  egg,  or  the  gluten  of  bread.  The  egg  should  be  beaten 
up  with  a  large  quantity  of  water  before  it  is  given.  Milk 
may  also  be  administered  in  large  quantities.  The  casein  it 
contains,  as  well  as  the  albumen  of  the  egg,  forms  an  in- 
soluble compound  with  the  mercury.  Small  rolls  of  zinc 
and  gold  foil  have  been  recommended  as  antidotes. 

The  subsequent  inflammation  should  be  treated  in  the 
same  manner  as  that  arising  from  arsenical  poisoning  [see 
Arsenic). 

Calomel  is  the  true  protochloride  of  mercury.  It  acts 
sometimes  as  an  irritant  poison,  but  there  are  few  cases  of 
destruction  of  life  from  its  use.     It  is  recognized  by  its 


246      EMERGEXCIES,  AND  HOW  TO  TREAT  THEM. 

extreme  insolubility.  The  bile  is  the  only  fluid  in  the  body 
which  exerts  a  solvent  action  upon  it,  and  that  only  in  very 
small  proportions.  Potash  and  ammonia  give  a  black  pre- 
cipitate ;  lime-water  gives  also  a  black  precipitate. 

COPPER. 

The  preparations  of  copper  in  common  use  are  the  sul- 
phate {blue  vitrioT)  and  subacetate  {verdigris).  The  sul- 
phate of  copper  is  employed  medicinally,  internally,  as  an 
emetic,  and  externally  as  an  escharotic.  Yerdigris  pos- 
sesses similar  properties,  but  is  little  used. 

Chronic  poisoning  from  copper  may  be  induced  by 
working  in  alloys  of  that  metal,  inhaling  copper-dust,  or 
eating  from  utensils  lined  with  that  metal. 

All  the  soluble  preparations  of  copper  are  corrosive 
poisons,  and  the  effects  on  the  system  similarly  manifested. 
The  quantity  of  sulphate  of  copper  which  will  destroy  life 
is  subject  to  great  variation.  Being  a  powerful  emetic, 
the  poison  is  rapidly  thrown  from  the  stomach,  and  the 
danger  lessened.  Nearly  an  ounce  of  the  poison  has  been 
taken  and  recovered  from,  while  in  another  instance  one 
drachm  has  been  known  to  destroy  life. 

Tests. — Ammonia,  potash,  and  soda,  give  a  bluish-white 
precipitate.  Ferrocyanide  of  potassium  gives  a  claret-red 
precipitate  {Taylor). 

When  the  system  becomes  slowly  impregnated  with 
copper,  there  are  a  rapid  loss  of  flesh  and  strength,  nausea, 
tendency  to  diarrhoea,  griping  abdominal  pains,  tympanitis, 
muscular  tremors,  retraction  of  the  gums,  with  a  purple  line 
around  the  edge  {Corrigan),  a  dry  cough,  paralysis,  dysen 
teric  discharges  from  the  bowels,  and  great  prostration. 


METALLIC  POISONS.  24:7 

In  acute  poisoning  there  are  intense  griping  pains  in 
the  abdomen,  profuse  greenish-colored  discharges  from  the 
stomach  and  bowels,  metallic  taste  in  the  mouth,  anxious 
facies,  vertigo,  headache,  dimness  of  vision,  muscular  trem- 
ors, a  rapid,  small  pulse,  paralysis,  and  sometimes  con- 
vulsions. 

After  death,  the  mucous  membrane  of  the  oesophagus, 
stomach,  and  intestines,  is  reddened  and  softened.  Ulcera- 
tion and  erosion  in  patches  are  found  in  different  parts  of 
the  canal. 

Treatment. — Ferrocyanide  of  potassium  is  recommended 
as  an  antidote  by  Schrseder.  Milk  and  honey,  or  white  of 
^^^^  and  milk  in  copious  draughts,  are  often  serviceable. 
Albumen  in  any  form,  or  sugar,  is  considered,  by  many, 
an  efficient  antidote. 

The  resulting  gastro-enteritis  is  treated  as  in  the  pre- 
ceding case?. 

LEAD. 

Every  soluble  salt  of  lead  possesses  poisonous  properties. 
The  carbonate  and  oxide  are  more  frequently  the  active 
agents  in  chronic  poisoning  than  any  other  preparations. 
The  acetate  (sugar  of  lead),  and  the  solution  of  the  sub- 
acetate  (Goulard's  extract),  occasionally  exert  a  deleterious 
effect  on  the  system,  when  given  in  ordinary  medicinal 
doses.  The  carbonate  of  lead  (white  lead)  is  more  severe 
in  its  action  than  the  other  salts.  Usually  a  very  large 
quantity  of  lead  is  necessary  to  destroy  life. 

Chronic  poisoning  is  of  frequent  occurrence,  from  using 
hair-dyes,  drinking  beer  or  water  which  flows  through  lead 
pipes,  constant  handling  of  the  thin  foil  covering  chewing- 
tobacco,  manufacturing  or  mixing  white  lead.     It  is  some- 


248      EMERGENCIES,  AND  EOW  TO  TREAT  THEM. 

times  produced  by  wearing  Brussels  lace,  the  material  of 
wliieli  owes  its  white  color  to  carbonate  of  lead. 

Tests. — Sulphuric  acid  throws  down  a  white  precipitate. 
Iodide  of  potassium  gives  a  yellow,  and  sulphuretted  hy- 
drogen a  black  precipitate. 

The  symptoms  of  poisoning  by  lead  appear  gradually. 
There  are,  at  first,  colicky  pains  in  the  abdomen,  and  con- 
stipation. The  attack  of  colic  {colica  jpidamim)  may  be 
very  severe,  or  so  slight  as  scarcely  to  demand  attention. 
It  is  paroxysmal  in  character.  The  bowels  are  constipated. 
A  blue  line  appears  around  the  edge  of  the  gums.  There 
are  "  thumb-drop  "  and  wrist-drop,"  from  paralysis  of  the 
extensor  muscles.  The  right  rectus  abdominalis  is  said  to 
be  the  first  muscle  afiected  by  the  paralysis.  The  retrac- 
tion of  the  abdomen  witnessed  in  these  cases  is  due  to 
paralysis  of  those  muscles.  Paraplegia  and  hemiplegia  exist 
in  rare  eases.  Loss  of  flesh  and  strength,  and  muscular 
tremors,  are  also  present. 

When  very  large  doses  of  lead  are  taken,  there  are  thirst, 
dryness  of  the  fauces,  burning  sensation  in  the  tliroat,  con- 
stipation, and  intense  colicky  pains  in  the  abdomen.  If  the 
bowels  are  moved,  the  faeces  will  be  found  to  possess  a  dark 
color  due  to  the  change  of  the  lead  into  the  sulphuret  in  the 
intestinal  canal  (the  same  color  is  also  observed  after  the 
administration  of  iron ;  the  iron  is  changed  into  the  sul- 
phuret). Yomiting  is  sometimes  i)rescnt ;  there  are  difficult 
respiration  and  oppression  over  the  proecordia.  Paralysis 
and  coma  precede  death. 

On  post-mortem  examination  there  is  usually  found 
abrasion  of  the  mucous  membrane  of  the  stomach  and 
intestines,  with  redness  and  congestion  in  isolated  patches; 


METALLIC  rOISONS.  249 

also,  a  grayisli-wliite  color  in  certain  portions,  from  the 
mixing  of  the  mucus  with  the  lead. 

Treatment. — In  chronic  poisoning,  iodide  of  potassium 
is  considered  the  best  eliminative.  It  joins  with  the  lead 
in  the  system  to  form  a  soluble  iodide  of  lead,  which  is  car- 
ried out  through  the  different  emunctories.  Sulphuric  acid 
is  sometimes  administered  for  the  same  purpose.  The  patient 
should  entirely  change  his  habits,  take  active  exercise  in  the 
open  air,  eat  nourishing  food,  and  keep  regular  hours. 
Quinine  is  a  useful  tonic  in  these  cases.  The  paralyzed 
limbs  may  be  treated  by  frequent  bathing  in  cold  water  and 
by  friction. 

In  acute  poisoning  from  lead,  the  stomach  should  first 
be  emptied  by  emetics,  or  with  the  stomach-pump.  Strong 
solutions  of  Epsom  salts  (sulphate  of  magnesia),  or  Glau- 
ber's salts  (sulphate  of  soda),  may  then  be  given  in  large 
quantities,  as  antidotes.  If  the  bowels  do  not  move,  castor- 
oil  should  be  given  until  free  evacuations  are  produced. 
Animal  charcoal  is  given  by  some.  Albumen  and  milk 
may  be  used  after  or  before  the  administration  of  the  salts 
of  magnesia  or  soda.  These  are  not  unfrequently  employed 
alone.  Taylor  advises  a  mixture  of  vinegar  and  sulphate  of 
magnesia  as  an  antidote  for  poisoning  by  the  carbonate  of 
lead. 

TAKTAEIZED  ANTIMONY. 

This  substance  is  prepared  by  adding  an  ounce  of  the 
oxide  of  antimony,  and  one  ounce  of  bitartrate  of  potasb  to 
eigbteen  ounces  of  water,  and  then  boiling  for  one  hour. 
Tartarized  antimony  is  used  in  medicine  as  an  emetic, 
sedative,  alterative,  diaphoretic,  and  expectorant.     In  large 


250      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

doses  is  an  irritant  poison.  The  ordinary  dose  for  an 
adult,  as  an  emetic,  is  from  one  to  two  grains ;  with  young 
persons  very  small  doses  will  often  produce  dangerous 
eftects.  Three-quarters  of  a  grain  has  been  known  to 
destroy  life  in  a  child  (  Wilton).  Ten  grains  is  the  smallest 
recorded  fatal  dose  in  an  adult.  Although  antimony  is 
capable  of  producing  rapid,  violent  constitutional  disturb- 
ances, yet  remedial  eflorts  are  generally  followed  by  re- 
covery.    It  is  not  apt  to  prove  fatal,  with  proper  care. 

Testa. — ^Nitric  acid  throws  down  a  white  precipitate, 
which  is  soluble  in  tartaric  acid.  Sulphuretted  hydrogen 
gives  a  characteristic  red  color  to  a  solution  of  antimony, 
and,  if  muriatic  acid  is  added  to  the  precipitate,  it  is  dis- 
solved. If  the  solution  is  then  added  to  water,  a  white  pre- 
cipitate appears. 

Chronic  poisoning  by  tartarized  antimony  is  distin- 
guished by  gradual  exhaustion,  nausea,  and  vomiting,  pain 
in  the  epigastrium,  a  small,  feeble  pulse,  pallid  surface,  and 
cold,  clammy  extremities,  sunken  eyes,  anxious  expression 
of  countenance,  and  metallic  taste  in  the  mouth. 

In  large  quantities  the  drug  produces  in  a  few  moments 
profuse  bilious  vomiting,  and  the  matter  vomited  is  soon 
mixed  with  blood.  Portions  of  mucous  membrane,  of  a 
grayish-white  or  dark-brown  color,  may  come  away  in 
small  pieces  {Taylor).  Diarrhoea  is  present  if  much  of  the 
poison  has  been  swallowed.  Signs  of  collapse  are  apparent : 
the  skin  becomes  cold  and  bathed  in  a  clammy  perspiration, 
the  pulse  is  feeble  and  rapid,  and  respiration  sighing.  A 
pustular  eruption  has  been  observed  on  tlie  skin  in  some 
cases.     Before  death,  the  patient  sinks  into  a  deep  coma. 

A  post-mortem  examination  shows  signs  of  inflan  imation 


METALLIC  POISONS.  251 

in  the  throat,  stomacli,  and  intestines.  Patches  of  mucous 
membrane,  softened  and  easily  detached  and  broken  down, 
are  found  in  the  throat  and  stomach,  and  occasionally  in  the 
small  intestines.  Peritonitis  is  found  in  a  small  proportion 
of  cases.     The  lungs  are  congested. 

Treatment. — Large  quantities  of  warm  water  should  be 
given,  to  promote  the  complete  evacuation  of  the  stomach. 
Strong  infusions  of  green  tea  may  be  taken  at  the  sa,me 
time  or  subsequently ;  various  vegetable  astringents,  as 
tannic  acid,  etc.,  are  also  used  as  antidotes.  Attempts 
should  be  made  to  counteract  the  collapse  by  hot  bottles  and 
blankets  applied  to  the  surface,  and  by  friction  of  the  ex- 
tremities. 

ZINC. 

Sulphate  of  zinc,  or  white  vitriol^  and  ^.uioride  of  zinc, 
are  energetic  poisons ;  the  former  is  an  irritant,  the  latter  a 
corrosive  poison.  The  sulphate  is  employed  in  medicine  as 
an  astringent,  nervine,  and  emetic.  Its  dose,  as  an  emetic, 
is  from  ten  to  twenty  grains.  The  chloride  of  zinc  in  solu- 
tion is  a  valuable  disinfectant. 

The  tests  for  zinc  are  ammonia,  ferrocyanide  of  potas- 
sium, and  sulphuretted  hydrogen,  all  of  which  give  a  white 
precipitate. 

In  poisoning  from  white  vitriol,  there  are  nausea  and 
vomiting,  pain  in  the  abdomen,  followed  by  all  the  signs  of 
collapse.  When  the  chloride  is  the  poisoning  agent,  the 
pain  and  collapse  are  greater ;  there  are  lividity  of  the  sur- 
face, vertigo,  and  dimness  of  vision.  In  the  evacuations 
from  the  stomach,  shreds  of  mucous  membrane  are  found. 

The  stomach,  after  death,  is  dark-colored ;  the  mucous 
membrane  thickened,  congested,  and  perhaps  ulcerated. 


252      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

Treatment. — "White  of  egg,  beaten  up  Avitli  milk  and 
water,  followed  by  infusions  of  astringent  medicines,  is  the 
chief  remedy  for  poisoning  from  the  sulphate. 

In  poisoning  from  the  chloride,  emetics  should  first  be 
given ;  the  albumen  in  milk  can  be  administered  when  the 
stomach  has  been  emptied. 

NITRATE   OF   SILVER. 

This  substance  is  a  corrosive  poison.  It  has  powerful 
escharotic  properties,  due  to  its  affinity  for  the  albumen  of 
the  tissues. 

In  poisonous  doses,  it  produces  intense  pain,  vomiting, 
and  purging.  Mucus,  blood,  and  shreds  of  mucous  mem- 
brane, are  found  in  the  excavations.  If  these  are  allowed  to 
stand,  they  become  dark  from  exposure  to  air. 

Common  salt  (chloride  of  sodium)  throw^s  down  a  white 
precipitate  with  solutions  of  nitrate  of  silver,  and  it  is  also 
given  as  an  antidote.  Mucilaginous  drinks  should  be  ad- 
ministered ad  lihitum.. 

PHOSPHORUS. 

Phosphorus  is  largely  employed  in  the  manufacture  of 
lucifer  matches.  It  is  seldom  used  for  medicinal  purposes. 
Children  are  frequently  poisoned  by  sucking  the  ends  of 
matches,  or  drinking  water  in  which  they  have  been  soaked. 
In  match-factories,  chronic  poisoning  from  inhalation  of 
phosphorus-vapor  is  of  common  occurrence.  The  symp- 
toms of  acute  poisoning  from  phosphoinis  are  peculiar  in  not 
developing  for  some  hours  after  the  poison  has  been  taken. 
A  small  amount,  one-tenth  of  a  grain,  has  caused  death. 

Phosphorus  is  recognized  by  its  peculiar  odor,  and  it8 
luminous  appearance  in  the  dark. 


METALLIC  POISONS.  253 

Chronic  poisoning  usually  manifests  itself  first  l>y  ordi- 
nary dyspeptic  symptoms ;  sucli  as  loss  of  appetite,  feel- 
ing of  weight  and  heat  in  the  epigastrium,  and  by  prostra- 
tion. There  are  also  nausea,  diarrhoea,  restlessness,  inability 
to  sleep,  pains  in  the  bones,  and  febrile  excitement,  which 
is  worse  toward  night.  If  the  exposure  to  the  poisonous 
vapor  have  been  of  long  duration,  necrosis  of  the  lower  jaw, 
low  grades  of  inflammation  in  various  parts,  and  congestion 
of  the  lungs,  will  be  found,  in  addition  to  the  other  symp- 
toms. 

In  acute  poisoning  there  are  vomiting  and  purging  of  a 
greenish-colored  substance,  which  soon  becomes  mixed  with 
blood  and  mucus.  The  ejections  and  breath  have  a  garlicky 
odor.  If  brought  to  a  dark  place,  they  exhibit  a  peculiar 
luminous  appearance.  There  are  intense  pain  in  the  abdomen , 
and  tympanites.  The  face  is  anxious,  skin  cold,  and  the  pulse 
is  rapid  and  small.  A  fatal  termination  does  not,  usually, 
take  place  until  a  day  or  two  has  elapsed  from  the  com- 
mencement of  the  symptoms,  and  in  some  cases  life  has 
been  prolonged  for  a  week. 

After  death  the  stomach  presents  signs  of  gangrenous 
inflammation.  The  mucous  membrane  is  intensely  red,  and 
easily  detached  and  broken  down.  There  may  be  perfora- 
tions in  the  wall  of  the  intestines,  passing  into  the  peri- 
toneal cavity.  Congestion  of  the  brain  and  serous  effusion 
into  the  ventricles  are  also  present.  The  viscera  have  a 
garlicky  odor,  and,  when  exposed  in  a  dark  place,  become 
luminous. 

Treatment. — Phosphorus  has  no  direct  antidote.  Taylor 
recommends  hydrated  magnesia,  and  the  free  use  of  demul- 
cent drinks,  and  albumen. 


CHAPTEE  XXIII. 

CORROSIVE    A  CIBS. 
OXALIC  Acm. 

This  substance  exists  in  combination  with  potash  in 
Bon*el,  with  lime  in  rhubarb  ;  it  is  found  also  in  a  free  state 
in  the  chick-pea.  It  is  made  by  the  action  of  nitric  acid  on 
sugar;  or  upon  rice,  gum,  starch,  etc.  Chemically,  it  is 
composed  of  one  atom  of  carbonic  oxide,  and  one  atom  of 
carbonic  acid,  making  its  formula  CgOs. 

Tlie  crystals  of  oxalic  acid  are  sometimes  mistaken  for 
those  of  Epsom  salts.  The  crystals  of  the  former  are  dis- 
tinguished by  having  a  sour  taste,  and  by  being  clearer 
and  more  transparent  than  those  of  Epsom  salts.  The 
crystals  of  the  latter  have  a  bitter  taste. 

Oxalic  acid  is  a  deadly  poison,  acting  with  great  ra- 
pidity, and  causing  death  in  from  five  minutes  to  half  an 
hour. 

Tests. — Chloride  of  calcium  gives  a  white  precipitate  of 
oxalate  of  lime ;  sulphate  of  copper,  a  bluish- white  precipi- 
tate of  oxalate  of  copper ;  and  nitrate  of  silver,  a  white  pre- 
cipitate of  oxalate  of  silver  ( Wood  &  Bache). 

Oxalic  acid,  when  given  in  a  concentrated  form,  pro- 
duces pain  in  the  throat,  oesophagus,  and   stomach.     The 


CORROSIVE  ACIDS.  255 

vomiting  is  associated  with  violent  retching.  There  are 
rapid  prostration,  syncope,  and  death. 

If  largely  diluted,  its  corrosive  action  is  decreased,  and  the 
symptoms  are  not  so  violent.  There  are  less  pain  and  vomit- 
ing, hut  stupor  and  prostration  are  more  distinctly  marked. 
Death  may  result  from  paralysis  of  the  heart.  Christosin 
states  that  the  mucous  membrane  after  death  has  a  scalded 
appearance,  that  dark-colored  spots  are  found  scattered 
through  the  whole  canal,  and  that  the  membrane  is  entirely 
destroyed  in  some  parts,  leaving  the  muscular  coat  bare. 

Treatment. — Emetics  should  be  given  and  followed  im- 
mediately by  the  antidotes.  Lime  or  magnesia  should  be  ad- 
ministered in  large  quantities  in  water.  The  lime  is  usually 
employed  in  the  form  of  the  carbonate  (common  chalk).  If 
this  cannot  be  had,  the  ceiling  of  the  room  may  be  scraped 
with  a  shovel  or  other  available  instrument,  and  the  substance 
thus  obtained  given  in  the  manner  prescribed.  Lime  and 
magnesia  form  insoluble  salts  by  combining  in  the  stomach 
with  the  oxalic  acid. 


SULPHUEIC  ACID. 

There  are  three  varieties  of  this  acid,  viz.,  the  anhy- 
drous, SO^;  commercial,  SO3+II0;  and  the  fuming  oil  of 
Kordhausin,  SOsHo  +  SOs. 

The  commercial  sulphuric  acid,  which  is  the  variety 
generally  employed  for  medicinal  purposes,  is  made  by 
burning  sulphur  and  nitrate  of  potash  together  in  a  leaden 
chamber  containing  water.  It  is  a  powerful  corrosive 
poison,  destroying  organic  tissues  when  brought  in  contact 
with  them.     It  has  a  powerful  affinity  for  water,  and  its 


250      EMERGENCIES,  AND  HOW  TO  TREAT  THEM. 

caustic  effect  is  due  to  the  abstraction  of  that  substance  from 
the  tissues.     It  makes  a  red  stain  on  black  clotli. 

Teste. — Chloride  of  barium  throws  down  a  white  pre- 
cipitate. 

In  poisoning  from  sulphuric  acid,  the  pain  is  most  in- 
tense in  the  mouth,  throat,  oesophagus,  and  stomach.  There 
are  great  pain  on  pressure,  vomiting  of  black  putrid  matter, 
dyspnoea,  small,  feeble  pulse,  anxious  expression  of  counte- 
nance, cold  extremities,  restlessness,  and  sometimes  con- 
vulsions. 

Treatment. — The  poison  may  be  neutralized  by  mag- 
nesia, or  carbonate  of  soda,  administered  in  solution,  thick 
soap-suds,  and  mucilaginous  drinks.  Unless  these  remedies 
can  be  given  directly  after  the  poison  has  been  swallowed, 
there  is  little  chance  of  saving  the  life  of  the  patient. 

KITEIC   ACID. 

ITitric  acid  is  made  by  the  action  of  sulphuric  acid  on 
nitrate  of  potash.  It  is  a  powerful  corrosive  poison.  In 
medicine  it  is  employed  as  a  tonic,  astringent,  and  anti- 
spasmodic. The  vapor  of  nitric  acid  is  reputed  a  good  dis- 
infectant. Inhaling  the  vapor  in  a  concentrated  form  has 
produced  death.  One  to  two  drachms  of  the  liquid  have 
been  known  to  destroy  life. 

Tests. — A  solution  of  morphia  added  to  nitric  acid  gives 
a  red  color,  wliich  afterward  changes  to  a  yellow.  If  the 
acid  is  boiled  in  water  containing  copper  filings,  red  fumes 
of  nitrous  acid  are  given  off.  "When  applied  to  clothing  it 
gives  a  yellow  stain. 

The  symptoms  of  poisoning  are  violent  pain,  extending 


CORROSIVE  ACIDS.  257 

from  the  mouth  to  the  epigastrium,  vomiting  of  yellowish 
and  greenish-black  material,  and  the  emission  of  fetid  gas, 
tympanitis,  urgent  dyspnoea,  small,  rapid  pulse,  and  collapse. 
Constipation  is  usually  present.  The  enamel  of  the  teeth 
will  be  found  partially  destroyed ;  the  tongue,  throat,  and 
fauces,  of  a  yellowish-brown  color,  and  very  much  swollen. 

If  poisoning  have  resulted  from  inhalations  of  the  va- 
por, there  will  be  great  pain,  difficulty  in  respiration,  and  the 
patient  may  die  asphyxiated  from  effusion  under  and  into 
the  mucous  membrane  of  the  larynx. 

After  death,  the  mucous  membrane  of  all  parts  of  the 
alimentary  canal  which  came  in  contact  with  the  poison  is 
deeply  corroded ;  in  some  parts  there  are  yellowish-brown 
stains,  in  other  parts  extensive  redness.  The  mucous 
membrane  is  readily  broken  down ;  in  many  cases  there  is 
congestion  of  the  lungs  and  larynx. 

Treatment.  —  Magnesia,    olive-oil,    and    mucilaginous 
drinks,  should  be  given  in  large  quantities. 


MUEIATIC   ACID. 

This  acid  is  made  by  the  action  of  sulphuric  acid  on 
chloride  of  sodium.  It  is  sometimes  called  sjpirit  of  salt. 
Cases  of  poisoning  by  it  are  rare. 

Tests. — If  the  acid  is  boiled  with  black  oxide  of  manga- 
nese, chlorine  is  evolved,  which  is  recognized  by  its  odor 
and  its  bleaching  properties.  If  a  rod  is  dipped  in  the 
acid  and  held  near  ammonia,  a  white  vapor  of  the  hydro- 
chlorate  of  ammonia  is  formed.  Nitrate  of  silver  throws 
down  a  white  precipitate  of  chloride  of  silver. 

The  symptoms  following  large  doses  resemble  those 
17 


253  EMERGENCIES,   AND   HOW   TO   TREAT   THEM. 

proclu<;ed  by  the  other  corrosive  acids.  They  are,  however, 
developed  more  slowly  ;  life  is  not  so  soon  destroyed,  and 
white  vapors  may  be  emitted  from  the  mouth. 

CAEBOLIC   AOID, 

Sometimes  called  oxide  of  phenyl,  or  phcnylic  acid,  is 
much  employed  at  the  present  day  as  a  disinfectant.  It  is 
obtained  by  the  distillation  of  coal-tar.  Very  few  cases  of 
poisoning  by  it  have  yet  occurred. 

A  concentrated  solution  taken  internally  excites  violent 
gastro-enteritis,  and  destroys  life  in  a  few  hours. 

After  death,  the  mucous  membrane  of  the  throat  and 
stomach  is  intensely  congested,  and  in  small  sections  soft- 
ened and  corroded. 

The  treatment  consists  in  evacuating  the  stomach,  and 
giving  large  quantities  of  magnesia,  mucilaginous  drinks, 
etc. 


CHAPTER  XXIY. 

C0RB08IVJE     ALKALIES. 
SALTS   OF   POTASH. 

Caebonate  of  potash  (pearlash)  acts  as  a  corrosive  poi- 
Bon  wlien  administered  in  a  concentrated  form.  It  gives 
a  yellowisli-wliite  precipitate  with  nitrate  of  silver.  The 
symptoms  following  its  administration  are  intense  pain  in 
tlie  throat  and  stomach,  pain  on  pressure  over  the  abdomen, 
vomiting  of  dark  materials,  which  consist  of  mucus,  blood, 
and  shreds  of  the  lining  membrane.  Diarrhoea  occurs  in 
all  cases.  On  examination,  the  mouth  and  throat  are  found 
of  a  dark-red  color,  and  very  much  swollen.  This  condition 
seriously  interferes  with  deglutition.  The  pulse  is  small, 
rapid,  and  weak,  and  the  countenance  anxious. 

After  death  the  mucous  membrane  of  the  throat  and 
stomach  is  of  a  dark-brown  color,  softened,  and  in  some 
portions  destroyed. 

Treatment. — Taylor  advises  the  use  of  citric  or  acetic 
acid,  lemon  or  orange  juice.  Oil  in  large  quantities,  and 
mucilaginous  drinks,  are  efficient  remedies. 

Hydrated  oxide  of  potassium,  or  caustic  potash,  is  dis- 
tinguished from  the  carbonate  by  giving  a  brown  precipi- 
tate with  nitrate  of  silver. 

The  symptoms  produced  by  poisoning  with  this  drug  are 


2Q0  EMERGENCIES,   AND   UOW   TO   TREAT   TUEM. 

similar  to  tliose  whicli  occur  after  administration  of  the  car- 
bonate, and  a  like  treatment  is  necessary. 

Binoxalate  of  potash,  sometimes  called  essential  salt  of 
lemon,  is  an  active  poison,  resembling  oxalic  acid  in  its 
eflects  on  the  system.  It  is  sometimes  mistaken  for  cream 
of  tartar.  The  latter,  however,  is  not  precipitated  from  its 
solution  by  the  sulphate  of  lime,  M'hile  the  former  is.  Ink- 
stains  are  removed  by  the  binoxalate,  which  furnishes  an- 
other distinguishing  point. 

The  symptoms  of  poisoning  are  violent  vomiting  and 
purging,  pain  in  the  stomach,  difficult  deglutition,  and  sigh- 
ing respiration,  small,  rapid  pulse,  cold  extremities,  great 
prostration,  and  muscular  spasms. 

Treatment  consists  in  the  administration  of  lime,  mag- 
nesia, and  mucilaginous  drinks. 


NTFRATE   OF   POTASH, 

Usually  known  as  saltpeti'e,  is  employed  medicinally  as  an 
antiseptic,  diuretic,  refrigerant,  diaphoretic,  and  sedative. 
In  doses  of  from  three  drachms  to  an  ounce  it  acts  as  a 
corrosive  poison. 

In  these  doses  it  causes  vomiting  and  purging  of  blood 
and  mucus,  violent  pain  in  the  abdomen ;  there  are  feeble 
pulse,  rapid  prostration,  insensibility,  and  death. 

Treatment. — The  stomach  should  be  emptied  by  emet- 
ics, and  mucilaginous  drinks  should  be  freely  adminis- 
tered ;  opium  should  be  given  to  relieve  pain. 

There  is  no  antidote  for  the  poison.  The  salts  of  soda 
correspond  with  the  salts  of  potash  in  their  peculiar  poison- 
ous action,  and  in  the  treatment. 


CORROSIVE  ALKALIES.  261 


AMMONIA. 


Strong  solutions  of  ammonia,  carbonate  and  mm-iate  of 
ammonia,  act  as  corrosive  poisons.  The  vapor  of  ammonia, 
when  inhaled  in  large  quantities,  excites  inflammation  of 
the  mouth,  fauces,  and  air-passages,  and  may  produce 
asphyxia.  Solutions  of  the  carbonate  {sal-volatile),  or  of 
gaseous  ammonia,  produce  violent  inflammation  in  the 
oesophagus  and  stomach,  and  corrode  the  mucous  mem- 
brane. The  carbonate  is  said  to  be  more  violent  in  its  ac- 
tion than  the  other  preparations. 

These  substances  are  recognized  by  their  peculiar  pene- 
trating odor. 

The  symptoms  of  poisoning  are  nausea,  and  vomiting  of 
mucus,  mixed  with  blood  and  shreds  of  mucous  membrane, 
pain  in  the  throat  and  epigastrium.  Perforations  of  the 
stomach  sometimes  take  place,  and  are  followed  by  perito- 
nitis. There  is  great  difiiculty  in  swallowing  and  breath- 
ing. The  mouth  is  tender  and  swollen,  the  face  is  anxious, 
the  pulse  rapid  and  feeble,  and  the  extremities  cold. 

After  death  the  blood  is  found  more  fluid  than  in  other 
cases  of  poisoning ;  there  are  extravasations  of  blood  in  the 
stomach  and  intestines,  and  congestion,  softening,  and  ero- 
sion of  the  mucous  membrane. 

Treatw^nt. — Yinegar,  acetic  acid,  diluted  milk,  and 
mucilaginous  drinks,  are  usually  given ;  opium  is  necessary 
to  relieve  pain. 


appe:n^dix. 


Page  20. 

I  have  used  the  aspirator  in  thirteen  cases  with  success. 
But  in  my  recent  cases  I  have  used  Colin's  instrument,  in- 
stead of  the  aspirator,  because  of  its  universal  applicability, 
and  also  on  account  of  its  simplicity  and  safety.  It  consists 
of  a  re5ervoir  or  basin  for  the  blood,  to  which  is  attached  a 
syringe — nothing  more  than  an  ordinary  syringe — "worting 
as  any  syringe  would.  To  this  is  attached  a  tube,  ending  in 
a  canula,  which  fits  accurately  a  canula  previously  inserted 
into  the  vein  of  the  patient.  The  entrance  to  the  tube  of 
exit  is  guarded  by  an  aluminum  ball-valve  which  excludes 
the  air,  and  permits  only  the  blood  to  enter.  Thus  one  of 
the  principal  dangers  in  transfusion  is  avoided. 

Though  Colin's  instrument  is  intended  to  throw  in  blood 
in  its  natural  state,  undefibrinated,  I  have,  in  the  majority  of 
my  cases,  in  order  to  make  the  operation  absolutely  safe,  de- 
fibrlnated  the  blood,  and  added  it  to  a  solution  of  ammonia 
and  water,  already  contained  in  the  basin  of  the  instrument. 

Page  38. 
I  have  lately  devised  a  tourniquet  on  the  principle  of  the 
"  safety-pin,"  which  obviates  danger  from  haemorrhage  dur- 
ing the  operation,  and  enables  the  surgeon  to  control  all  the 


APPENDIX.  2G3 

bleeding  parts  without  difficulty.  The  instrument  was  first 
employed  to  control  bleeding  from  the  lingual  artery  during 
amputation  of  the  tongue.  It  can  be  utilized  in  a  great  va- 
riety of  operations. 

Page  54. 
Dr.  Lewis,  of  Philadelphia,  has  devised  an  ingenious 
method  of  suppressing  haemorrhage  from  the  intercostal  ar- 
teries. He  passes  the  handle  of  an  ordinary  door-key  through 
the  wound,  turns  the  end  at  right  angles  to  the  rib,  then  by 
very  slight  pressure  compresses  the  artery. 


IKDEX. 


Abdomen,  -wounds  of,  59. 
Acetate  ot  lead,  poisoning  by,  247. 
Aconite,  poisoning  by,  '218. 
Accidental  lisemorrbage,  42. 
Acupressure,  18. 
Air  in  veins,  71. 
Air,  impure,  effects  of,  142. 
Albuminuria,  124,  184. 
Alcohol,  poisoning  by,  127,  191,  225. 
Ammonia,  poisoning  by,  261. 
Antimony,  poisoning  by,  249. 
Arsenic,  poisoning  by,  239. 
Arteries,  ligation  of,  65. 
Arterial  haemorrhage,  diagnosis  of,  12. 
Articulations,  wounds  of,  62. 
Asthma,  dyspnoea  in,  165. 
Asphyxia,  from  compression  of  throat, 
145. 

of  chest,  148. 

inhalation  of  gases,  149. 

obstructions  in  air-passages,  85. 

drowning,  152. 

injuries  to  cord,  157. 
Atropia,  poisoning  by,  215. 

Base  of  the  skull,  fracture  of,  121. 
Belladonna,  poisoning  by,  215. 
Bladder,  haemorrhage  from,  34. 

wounds  of,  60. 
Bleeding  from  the  mouth,  23. 

nose,  21. 

stomach,  23. 

bronchi,  29. 

lungs^  29. 

intestines,  29. 

kidneys,  35. 

uterus,  41. 

urethra,  35. 
Blood-vessels,  wounds  of,  65. 
Blood-changes,  non-aeration  of,  143. 

extravasation  of,  into  intercellular 
tissuCj  38. 

into  brain-tissue,  119. 


Brain,  compression  of,  118. 

concussion  of,  130. 

contusion  of,  130. 

inflammation  of,  121. 
Brachial  artery,  ligation  of,  68. 

pressure  on,  15, 16. 
Brigiit's  disease,  convulsions  in,  154. 

coma  in,  124. 
Bronchial  tubes,  foreign  bodies  in,  85, 
Burns,  101. 

Calomel,  poisoning  by,  245. 
Calabar-bean,  poisoning  by,  231. 
Camphor,  poisoning  by,  244. 
Capillaries,  hajmorrhage  from,  12. 
Carbonic  acid,  poisoning  by,  150. 
Carbonic  oxide,  poisoning  by,  151. 
Carbolic  acid,  poisoning  by,  258. 
Carbonate  of  lead,  poisoning  by,  247. 
Carbonate  of  potash,  poisoning  by,  259. 
Carburetted  hydrogen,  poisoning   by, 

151. 
Carron-oil  {see  Burns). 
Carotid  arteries,  ligation  of,  66. 

pressure  on,  15. 
Cautery  in  hemorrhage,  19. 
Centipedes,  bites  of,  84. 
Charcoal-vaporj  poisoning  by,  151. 
Cliloroform,  poisoning  by,  225. 
Chloral,  poisoning  by,  227. 
Cicatrization  of  burns  {see  Burns). 
Coal-gas,  poisoning  by,  151. 
Cocculus  indicus,  poisoning  by,  223 
Colchicum,  poisonmg  by,  237. 
Colic,  210. 
Cold,  effects  of,  in  haemorrhage,  16. 

on  the  system,  109. 
Compression  of  brain  {see  Brain). 
Coma  from  compression,  118. 

urffimia,  124. 

alcohol,  127. 

embolism,  123. 

hysteria,  128. 


INDEX. 


265 


Coma  from  epilepsy,  180. 

Congestion  of  the  lungs  (dyspnoea  in), 

168. 
Coniura  maculatum,  poisoning  by,  216. 
Convulsions  from  apoplexy,  190. 

uriBmia,  184. 

epilepsy,  187. 

hysteria,  192. 

rum,  191. 
Concussion  of  brain,  130. 
Corrosive  sublimate,  poisoning  by,  248. 
Croup,  dyspnoea  in,  167. 
Croton-oil,  poisoning  by,  236. 
Coup-de-soleil,  158. 

Death,  signs  of,  147. 

Degeneration  of  vessels  in  brain,  119. 

Dentition,   convulsions  during  period 

of,  178. 
Diaphragm,  action  of,  140. 
Digitalis,  poisoning  by,  221. 
Dislocation  of  cei'vical  vertebra,  209. 
Dissection-wounds,  74. 
Dog-bites  {see  Hydrophobia), 
Drowning,  152. 
Duodenum,  ulceration  of,    in    burns, 

105, 
Dyspnoea  in  asthma,  166. 

croup,  167. 

cardiac  disease,  169. 

pulmonary  oedema,  170. 

oedema  glottis,  172, 

Ear,  foreign  bodies  in,  96 
Eclampsia,  176. 
Embolism,  coma  from,  123, 
Enterocele  (see  Hernia), 
Epistaxis,  21. 

Epilepsy  {see  Convulsions). 
Epiglottis,  wounds  of,  47, 
Ether,  poisoning  byj  226. 
Eye,  foreign  bodies  in,  98. 

Falling  sickness  {see  Epilepsy). 
Fseces,  involuntary  passage  of,  in  com- 
pression, 120. 
Femoral  artery,  ligation  of,  69. 

pressm-e  on,  16. 

hernia,  operation  for,  116. 
Fits  (see  Convulsions). 
Fibrinous  coagula  after  ligation,  65. 
Food,  indigestible,  effects  of,  177. 
Foreign  bodies  in  eye,  98. 

nose,  95. 

larynx,  85. 

bronchial  tubes,  85. 

lungs,  88, 

pharynx,  91. 

oesophagus,  92. 

urethra,  99. 

rectum,  100. 
Fracture  of  skull  (see  Compression), 


Gastritis,  from  poisons  (see  Poisons), 
Genitals,  wounds  of,  60, 

bleeding  from,  99. 
Glottis,  oedema  of,  172. 
Globus  hystericus,  cause  of,  128. 
Gunshot-wounds,  63. 

Hsematemesis,  23, 
Hajmathorax,  55, 
Haemoptysis,  29. 
Htemorrhage,  general,  9. 

internal  (see  Bleeding). 
Hajmorrhagic  diathesis,  13. 
Hasmorrhoids,  bleeding  from,  27. 
Haut-mal  (see  Epilei^syj. 
Heart,  wounds  of,  56. 
Hematuria,  35. 
Hemlock,  poisoning  by,  216. 
Hemiplegia,  120. 
Henbane,  poisoning  by,  217. 
Hernia,  strangulated,  112. 
Hospital  cases,  5,  9,  10,  11,  62,  79,  84, 

102,  128,  213. 
Hysteria,  128, 192. 
Hydrophobia  in  animals,  78. 

in  man,  78. 
Hydrochloric  acid,  poisoning  by,  257. 
Hydrocyanic  acid,  poisoning  by,  227 

Ice  in  haemorrhage,  16. 

Ileus  (see  Hernia). 

Infantile  convulsions,  177. 

Inguinal  hernia,  115. 

Inhalation  of  oxygen  (see  Asphyxia). 

Innominata  artery,  ligation  of,  '66. 

Insolation  (see  Sunstroke). 

Insect  bites,  83. 

Intercostal  vessels,  bleeding  from,  54. 

pressure  on,  54. 
Internal  mammary  artery,  ligation  of, 
54, 

Joints,  wounds  of,  62. 
Jugular  veins,  relations  of,  67. 

Kidneys,  disease  of,  as  causes  of  com? 
and  convulsions  (see  Coma), 
hcemorrhage  from,  3b. 

Laceration  of  perinceum,  60. 
Larynx,  wounds  of^  47. 

foreign  bodies  m,  85. 
Laryngotomy,  89. 
Laryngismus  stridulus,  169, 
Lead,  poisoning  by,  247. 
Ligation  of  arteries,  65, 

innominata,  66. 

subclavian,  67 

carotid,  66, 

axillary,  6B. 

brachial,  68. 

radial,  68. 

ulnar,  69. 


26G 


INDEX. 


Litigation  of  arteries,  femoral,  69. 

popliteal,  70. 

tibials,  To. 
Light,  carburetted  hydrogen,  poisoning 

by,  151, 
Liver,  rupture  of,  60. 
Lung,  wounds  of,  50. 
Lobelia,  poisoning  by,  222. 

Mad  animals  {see  Hydrophobia). 

Mala?na,  27. 

Marshall  Hall's  method  of  artificial 
respiration,  156. 

Matches,  poisoning  by  {see  Phospho- 
rus). 

Menorrhagia,  41. 

Metrorrhagia,  41. 

Mercury,  243. 

Morphia,  poisoning  by  (see  Opium). 

Mouth,  luemorrhuge  from    {eee  ]31eed- 

Mushrooms,  poisoning  by,  223. 

Narcotics,  poisoning  by,  211. 

Nares,  plugging  of,  23. 

Neck,  ■wouiids  of,  48. 

Nitrogen,  effects  of  inhalation,  149. 

Nitrate  of  silver,  poisoning  by,  252. 

potash,  poisoning  by,  260. 
Nitric  acid,  poisoning  by,  256. 
Nose,  bleeding  from,  21. 

foreign  bodies  in,  95. 
Nux-vomica,  poisoning  by,  232. 

Obstruction  in  air-passages  (s«e  Foreign 

Eodies'). 
(Edema  glottis,  172. 
CEsophagotomy,  95. 
(Esophagus,  foreign  bodies  in,  92. 
Opium,  poisoning  by,  211. 
Oxalic  acid,  poisoning  by,  254. 

Pain,  effects  of,  in  bums  (see  Burns). 
Palmar  arcli,  wounds  of,  69. 
Paralysis  in  compression  (see  Compres- 

'siou). 
Paracentesis  thoracis,  55. 
Pericardium,  wounds  of,  56. 
Pericarditis  (see  Wounds). 
Penetrating  wounds  of  chest,  51. 

abdomen,  57. 
Penis,  haemorrhage  from,  38. 
Pftritonffium,  wounds  of,  57. 
Pharynx,  foreign  bodies  in,  92. 
Phosphorus,  poisoning  by,  252. 
Pia  mater,  spasms  of  vessels  of.  180. 
Piles,  bleeding  from,  27. 
Placenta  pnevia,  42. 
Pneumocele,  53. 
Pneumothorax,  53. 
Poisonous  wounds,  74. 
Poisons,  vegetable,  211. 

metallic,  239. 


Poisons,  corrosive,  254. 

irritating,  235. 
Popliteal  space,  pressure  in,  16. 
Post-partuni  hiVMnorrhage,  43. 
Potasli,  carbonate  of,  poisoning  by,  269. 

nitrate  of,  260. 

binoxalate  of,  2G0. 

oxide  of,  259. 
Premature  labor,  induction  of,  186. 
Pressure  in  general  luemorrhage,  14. 
Pressure  on  carotid  artery,  15. 

subclavian,  15, 

axillary,  15. 

brachial,  16. 

ulna,  16. 

on  abdominal  aorta,  16. 

femoral  artery,  16. 

popliteal,  15. 
Presentations,  abnormal,  208. 

Eabies  (see  Hydrophobia). 

Kadiul  artery,  ligation  of,  68. 

Kattlcsnake-bites,  81. 

Eeaction    in  concussion  (see  ConcuB- 
sion). 

Eeady  method  of  artificial  respiration, 
156. 

Kespirationj    suspension  of    (see   As- 
phyxia), 156. 

Retention  of  urine,  207. 

Rupture  of  liver,  60. 
bladder,  60. 
cerebral  vessels,  119. 

Salivation    from    mercury    (see    Mer- 
cury). 

Savin,  oil  of,  poisoning  by,  236. 

Secondary  asphyxia,  154. 

Serpents,  bites  of,  81. 

Shock  (see  Syncope). 

in  burning  (see  Burns). 

Soda,  poisoning  by,  200. 

Spasms^  tonic  and  clonic  (see  Convul- 
sions). 

Spontaneous  combustion,  103. 

Stramonium,  poisoning  by,  221. 

Stomach,  bleeding  from  (see  Bleeding). 

Stertor,  cause  of  (see  Coma). 

Sudden  death  (see  Syncope). 

Sulphate  of  zinc,  poisoning  by,  251. 
of  copper,  poisoning  byj  246. 

Sulphuretted  hydrogen,  poisoning  by, 
149. 

Sunstroke,  158, 

Sulphuric  acid,  poisoning  by,  255. 

Sylvester's  method  of  artificial  respira- 
tion, 156. 

Syncope,  133. 

Tapping  of  chest,  55. 

of  bladder  tlirough  rectum,  208. 
Tampon,  application  of,  205. 
Tarantula,  oites  of,  84- 


INDEX. 


267 


Taxis  {see  Hernia). 

Tetanus,  193. 

Thorax,  wounds  of,  50. 

Thoracic  viscera,  wounds  of,  51,  5(j. 

Thrombus  (see  Coma). 

Tibial  arteries,  ligation  of,  70. 

Tourniquet,  14. 

Tobacco,  poisoning  by,  219. 

Trachea,  foreign  bodies  in,  87. 

Tracheotomy,  90. 

Transfusion,  20. 

Transverse  presentations,  204. 

Ulnar  artery,  ligation  of,  69. 
Umbilical  cord,  shortness  of,  202. 

prolapse  of,  201. 
Upas-tree,  poisoning  by,  231, 
Uraemia  {see  Coma  and  Convulsions). 
Urea,  poisoning  by,  125. 
Urethra,  bleeding  from,  35. 
Urine,  blood  in,  35. 
Uterus,  rupture  of,  192. 

Vhgina,  tamponing  of,  205. 


Veins,  wounds  of,  71. 

air  in,  71. 
Veratria,  poisoning  by,  237. 
Vessels,  wounds  of,  65. 
Venesection    in    apoplexy    {see    Com- 
pression). 
Volvulus,  114. 

"Wounds  of  throat,  47. 

thora.v,  50. 

lungs,  51. 

pericardium,  56. 

heart,  56, 

abdomen,  57. 

intestines,  57. 

bladder,  60. 

urethra,  61. 

arteries  and  veins,  65 

gunshot,  63. 

perinseum,  60. 

joints,  62. 
Woorara,  poisoning  by,  ^r'A. 

Zinc,  251. 


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and  20,  1884.     Small  8vo.     Cloth,  $5.00. 

TYNDALL  (JOHN).  Essays  on  the  Floating  [Matter  of  the  Air,  in  Relation  to 
Putrefacation  and  Infection.     12nio.     Clutli,  $1.50. 

ULTZMANN  (ROBERT).  Pyuria,  or  Pus  in  the  Urine,  and  its  Treatment. 
Translated  by  permission,  by  Dr.  Walter  B.  Piatt.     12mo.     Cloth,  $1.00. 

VAN  BUREN  (W.  II.).  Lectures  upon  Diseases  of  the  Rectum,  and  the  Sur- 
gery of  the  Lower  Bowel,  delivered  at  Bellevue  Hospital  Medical  College. 
Set'ond  edition,  revised  and  enlarged.     8vo.     Cloth,  $3.00;  sheep,  $4.00. 

VAN  BUREN  (W.  H.).  Lectures  on  the  Principles  and  Practice  of  Surgery. 
Delivered  at  Bellevue  Hospital  Medical  College.  Edited  by  Lewis  A.  Stim- 
son,  M.  D.     8vo.     Cloth,  $4.00 ;  sheep,  $5.00.j 

VAN  BUREN  and  KEYES.  A  Practical  Treatise  on  the  Surgical  Diseases  of 
the  Cenito-Urinary  Organs,  including  Syphilis.  Designed  as  a  Manual  for 
Students  and  Practitioners.  "With  Engravings  and  Cases.  By  W.  H.  Van 
Bureu,  M.  D.,  and  Edward  L.  Keyes,  M.  D.  8vo.  Cloth,  $5.00;  sheep, 
$G.OO. 

VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  of  Children.  Translated 
and  edited  by  II.  Raphael,  M.  D.  Third  American  from  the  eighth  German  edi- 
tion, revised  and  enhirged.  Illustrated  by  six  Litiiographic  Plates.  8vo. 
Cloth,  $4.50  ;  sheep,  $5.50. 

WAGNER  (RUDOLF).  Hand-Book  of  Chemical  Technology.  Translated' and 
edited  from  the  eiglith  German  edition,  with  extensive  Additions,  by  William 
Crookes.     With  336  Illustrations.     8vo.     Cloth,  $5.00.  ^ 

WALTON  (GEORGE  E.).  Mineral  Springs  of  the  United  States  and  Canadas. 
Containing  the  latest  Analyses,  with  full  Description  of  Localities,  Routes, 
etc.     Second  edition,  revised  and  enlarged.     12mo.     Cloth,  $2.00. 

WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases :  Their  Symptoms  and 
Treatment.    A  Text-Book  for  Students  and  Practitioners.    8vo.    Cloth,  $3.00. 

WEEKS  (CLARA  S.).  A  Text-Book  of  Nursing.  For  the  Use  of  Training- 
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Questions  for  Review  and  Examination,  and  Vocabulary  of  Medical  Terms. 
12mo.     Cloth,  $1.75. 

WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.     8vo.     Cloth,  $4.50. 

WYLIE  (WILLIAM  G.).  Hospitals:  Their  [History,  Organization,  and  Con- 
struction.    8vo.     Cloth,  $2.50. 


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